The authors of this study acknowledge that long-term alcohol abuse is detrimental to memory function and can cause neuro-degenerative disease. On the other hand there is evidence that light-to-moderate alcohol consumption may decrease the risk of cognitive decline or dementia. They followed 3202 subjects, 75 years of age or older, without dementia at outset for a 3-year period. Half of them consumed alcohol, in general less than two drinks per day. After controlling for a number of potential confounders current alcohol consumption was associated with a 29% decrease in overall dementia incidence and a 42% decrease in Alzheimer dementia. The authors note that the alcohol consumption may not be causal—perhaps “participants who drink alcohol sensibly also have a healthier lifestyle in terms of physical, dietary and mental perspectives”.

Therapy with β receptor blockers (β-blockers) is associated with an improved clinical outcome in patients with cardiovascular diseases, including hypertension. However, their use in those with peripheral arterial disease (PAD) has been limited because of the potential impact on vasomotor tone which can have negative implications, especially in PAD patients with critical limb ischemia. The authors of this study note that newer third-generation β-blockers like carvedilol or nebivolol have vasodilating properties, which might confer these drugs a selective advantage. This report concerns a randomised trial in which patients with intermittent claudication and hypertension were treated with 5mg of nebivolol or 95mg of metoprolol once daily. After the 48 week treatment period, ankle-brachial index and absolute claudication distance improved significantly in both patient groups (P>0.05 for both), with no difference across treatments. Both drugs were equally effective in controlling the hypertension.

We do not have nebivolol in New Zealand but we presume the results would be the same with carvedilol. In any case it would seem that the greatly cheaper metoprolol is an appropriate drug for such patients.

There has been suspicion that NSAID usage may predispose patients to develop AF. This population-based control study from Denmark attempts to elucidate. 32,606 patients with AF were matched with 325,918 control subjects. They report that 2925 cases (9%) and 21,871 controls (7%) were current users of either non-selective NSAIDs or COX 2 inhibitors. Compared with no use, the incidence rate ratio for the association between current use and atrial fibrillation or flutter was 1.33 for non-selective NSAIDs and 1.50 for COX 2 inhibitors. Adjustments for risk factors, such as heart failure, valvular heart disease, thyrotoxicosis, etc reduce the rates to 1.17 for the non-selective NSAIDs and 1.27 for COX 2 inhibitors. So they conclude that there is a positive correlation that is strongest for COX 2 inhibitors and for new users of the drugs. An editorial writer notes that the association may not be cause and effect and speculates that underlying inflammatory conditions may increase the risk of AF and prompt the use of NSAIDs. However, he recommends they should be used with caution in older patients.

Coronary artery disease (CAD) has long been known to be a factor increasing the post-operative mortality rate. Less is known of the effects of heart failure (HF) and atrial fibrillation (AF). This population-based cohort study from Canada sets out to evaluate these variables and their effects on post-operative mortality. Data from over 38000 such patients is analysed. They compared outcomes in terms of mortality in four cohorts—non-ischaemic HF, ischaemic HF, CAD and AF. The unadjusted 30-day post-operative mortality was 9.3% in NIHF, 9.2% in IHF, 2.9% in CAD, and 6.4% in AF (each versus CAD, P<0.0001). The findings were very similar when the analysis was performed on those undergoing minor surgical procedures such as colonoscopy, cystoscopy or cataract surgery. Interesting and important findings.

Acute exacerbations of COPD are common and often require hospital admission. They significantly impair quality of life and have a high mortality rate. These researchers note that the macrolide antibiotics have immunomodulatory anti-inflammatory and anti-bacterial effects which would make them suitable for preventing exacerbations of COPD. Accordingly they have performed a randomized trial to determine whether azithromycin decreased the frequency of exacerbations in participants with COPD who had an increased risk of exacerbations but no hearing impairment, resting tachycardia, or apparent risk of prolongation of the corrected QT interval. They randomised 1142 such patients to receive either azithromycin 250mg daily or placebo for one year in addition to their usual care. The azithromycin treated patients had a significant decrease in exacerbations and a significant improvement in their quality of life. They also had a significant increase in hearing decrements. So they regard the treatment as useful. However, this intervention could change microbial resistance patterns which might well be bad news in a wider sense. Anyway it will not take on in New Zealand as we reserve this antibiotic for patients who have cystic fibrosis.