Journal of the New Zealand Medical Association, 08-June-2012, Vol 125 No 1356
There are reasons why coffee drinking might be harmful. Caffeine is a stimulant and there are studies that show an association with increased LDL-cholesterol levels and short-term increases in blood pressure.
This paper reports on a study from the National Institutes of Health in the USA. Over 400,000 adults, none of whom had cancer, heart disease or stroke, were followed over 13 years and their coffee consumption evaluated with respect to their mortality.
The researchers conclude that inverse associations were observed for deaths due to heart disease, respiratory disease, stroke, injuries and accidents, diabetes, and infections, but not for deaths due to cancer. However, they also observe that “whether this was a causal or associational finding cannot be determined from our data.”
N Engl J Med 2012;366:1891–904.
Rheumatoid patients are known to have increased risks of cardiovascular disease but the association with atrial fibrillation and stroke is less well documented. This study from Denmark included the entire Danish population(!) over the age of 15 years. The study period was 1997 to 2009 and over this time 18,247 people developed rheumatoid arthritis. They report that rheumatoid arthritis was associated with a 40% increase in risk of atrial fibrillation (8.2 cases per 1000 person years compared with 6.0 cases per 1000 person years in age and sex matched controls); the risk of stroke was also significant greater that in the general population.
They recommend that an annual cardiovascular risk assessment would be appropriate for rheumatoid arthritis patients.
The authors of this paper note that in chronic heart failure, there is a significant difference between the sexes in aetiology, ventricular function, comorbidities, and exercise capacity. While in men, ischaemic heart disease is the main cause of heart failure, it is hypertensive heart disease in women.
Based on these and other points they speculate on the possibility that different drugs or combinations may have different outcomes in the management of chronic heart failure in men and women. Their comprehensive review includes consideration of ACE-inhibitors, beta-blockers, angiotensin receptor blockers, and aldosterone antagonists. They note that there are reports noting that these agents may have differential gender outcomes but overall evidence both from randomised trials, and registry data from hospital- and community-treated patients, do not support the idea that women obtain less benefit from any of the current major anti-failure drugs than men.
Cardiovascular Therapeutics 2012;30:182–92.
About 20% of patients with venous thrombosis or embolism but no defined risk factors have a recurrence within the first 2 years after stopping anticoagulation therapy.
Continuing anticoagulants for longer than 2 years is an option but is inconvenient because of monitoring requirements and the risk of haemorrhage. This study evaluates the role of the low dose aspirin. 403 patients were randomly assigned to aspirin 100 mg daily or placebo after they had completed 6–18 months anticoagulant treatment. At 2 years the thromboembolism rate was nearly halved in the aspirin treated patients (6.6% vs 11.2% per year). Adverse events were similar in the two groups, one patient in each group suffering a major bleeding episode.
N Engl J Med 2012;366:1959–67.
The ACP guideline authors note that over 25 million people in the USA have type 2 diabetes so treatment guidelines are important. After a systematic review of the literature they recommend that clinicians should prescribe oral medications for such patients when lifestyle modifications, including diet, exercise, and weight loss, have failed to adequately improve hyperglycaemia.
Metformin is their first choice as they believe it is the most effective agent and has fewer adverse effects than the sulfonyureas. If this is inadequate they recommend adding a second oral agent. They found no evidence to support any one class of agent as the preferred second drug.
And finally, patients with persistent hyperglycaemia despite oral agents and lifestyle interventions may need insulin therapy.
Ann Intern Med 2012;156:218–31.
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