Tony Breu MD joins us for some hotcakes, and “cold cakes” including: how aspirin and zodiac sign affect the treatment of acute MI, a recent study on how exercise is probably still good for you, the recently announced REDUCE-IT trial, and the evidence (or lack thereof) for the treatment of hypertensive urgency. Welcome to another edition of Hotcakes and Hot Takes, where we discuss the most interesting articles and news that we have been reading. Special guest is the prolific Dr. Tony Breu (@tony_breu) who is an Assistant Professor of Medicine at Harvard Medical School and a Hospitalist and Director of Internal Medicine Resident Education at the VA Boston Healthcare System. He is known for his series on “Things We Do For No Reason” as well as his thought-provoking “Tweetorials” online. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST on day of release).
Written and Produced by: Sarah Phoebe Roberts MPH, Christopher Chiu MD
CME Questions: Christopher Chiu MD
Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD, and Christopher Chiu MD
Guest Presenter and Content Planning: Anthony Breu MD
Editor: Christopher Chiu MD
Cover-Art: Christopher Chiu MD
Compared to placebo, what treatment is more effective at preventing vascular mortality among patients with recent suspected acute myocardial infarction (AMI): 1.5 million units (MU) of IV streptokinase administered once, 162.5 mg aspirin taken orally QD for one month, both treatments together, or neither treatment.
Compared to placebo, aspirin alone and streptokinase alone significantly reduced short-term (five weeks post-discharge) and longer-term (15 months) vascular mortality. However, optimal effectiveness was achieved by administering aspirin and streptokinase together. This was the first study to show clinical efficacy of aspirin in reducing vascular mortality in acute MI.
Analysis by zodiac sign underscores the potential failings of subgroup analysis and the likelihood of spurious associations by chance alone as statistical significance was lost in the combination of the Libra and Gemini participants.
What is the relationship between cardiorespiratory fitness, as measured by performance on exercise treadmill testing (ETT or ‘stress testing’), and all-cause mortality among adults?
Hazard ratios calculated for each performance category confirmed that better performance on ETT was associated with a reduced risk of mortality. There was an 80% reduction in mortality risk for those who performed at the ‘elite’ level compared to participants in the ‘low’ performance category. Extremely high CRF (i.e. ‘elite’ performance) is associated with the greatest reduction in mortality risk.
See also this NEJM editorial pointing out that this study allays previous concern re: “U shaped” curve suggesting increased mortality in elite athletes due to myocardial fibrosis, atrial fibrillation, and coronary artery calcification.
The pharmaceutical company Amarin Corporation has released initial results from the REDUCE-IT™ trial, which examines the effect of their fish-oil derived product Vascepa® (icosapent ethyl, also known as AMR101) on cardiovascular (CV) event incidence. Study participants are patients at higher risk of CV events who are currently taking statin drugs to treat hyperlipidemia.
REDUCE-IT trial participants with controlled LDL but still elevated triglycerides (150-499 mg/dL range) who were assigned to the icosapent ethyl group experienced an approximately 25% reduction in risk of CV events such as MI, stroke, and angina.
This study, published in 1967, examined whether treating essential hypertension with hydrochlorothiazide + reserpine + hydralazine hydrochloride was superior to placebo among adult male patients. Adverse health events tracked for ~2 years.
Approximately 39% of the placebo group experienced severe adverse health events, including 4 deaths, compared to ~3% of the medication group (no patients in the treatment group died). This study was important in establishing that treating essential hypertension is critical to the prevention of adverse outcomes such as stroke, MI, heart failure, renal failure, hospitalization and death.
By current standards, the ethics of this study are debatable. At the very least, it is likely that it would have been stopped earlier given the enormous difference in outcomes between the two arms.
Is it necessary to treat hypertensive urgency (SBP ≥ 180, DBP ≥ 120, with no evidence of end-organ damage) among adult patients in hospital settings with medication designed to rapidly reduce blood pressure? What is the evidence?
Unless hypertension is accompanied by end-organ damage (and therefore, actually hypertensive emergency), acutely lowering a patient’s blood pressure is unnecessary and may even be harmful. If reversible treatable causes such as missed doses of outpatient medications or pain cannot be immediately identified, allow the patient to rest for 30 minutes, then reassess their blood pressure with correct technique. If still elevated, consider augmentation of their outpatient regimen and arranging close outpatient follow-up after discharge.
Listeners will learn about relevant medical literature, with emphasis on breaking news and recently published research.
After listening to this episode listeners will…
Dr. Breu reports non relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
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