Journal of the New Zealand Medical Association, 29-June-2012, Vol 125 No 1357
It is generally acknowledged that warfarin is much more efficacious than aspirin in the prevention of ischaemic strokes in patients with atrial fibrillation. This report concerns a randomised trial comparing warfarin and aspirin treatment in patients in sinus rhythm who have a reduced left ventricular ejection fraction. They followed 2305 patients for up to 6 years. The primary outcome was the time to the first event in a composite end point of ischemic stroke, intracerebral haemorrhage, or death from any cause.
Their conclusions were that among patients with reduced LVEF who were in sinus rhythm, there was no significant overall difference in the primary outcome between treatment with warfarin and treatment with aspirin. A reduced risk of ischemic stroke with warfarin was offset by an increased risk of major haemorrhage. The choice between warfarin and aspirin should be individualised. The daily dose of aspirin was 325mg and we could speculate whether a lower daily dosage might have been better or worse.
N Eng J Med 2012;366:1859–69.
The authors of this paper note that data from randomised clinical trials have suggested an increased risk of cancer with angiotensin receptor blockers, but the most recent and comprehensive meta-analysis found no association. Their report concerns a cohort study involving 377,649 individuals,, comparing the effects of exposure to angiotensin receptor blockers or ACE inhibitors between 1995 and 2010. The information was derived from UK primary practices. They report that “we found no overall association with cancer; we detected small absolute risk increases for breast and prostate cancer, but the results did not support a causal effect”.
The authors of this paper have previously reported on the favourable effects of nebulised frusemide in a patient in whom intravenous access was not attainable. They reported that after administering 80mg of nebulised frusemide, there was an immediate improvement in oxygen saturation, the chest was clearer on auscultation and there was increased diuresis, In order to assess the haemodynamic effects of such treatment they have performed a trial in which 32 patients with stable advanced heart failure were randomised to receive either 40mg (4ml) of nebulised frusemide or 4ml of normal saline. Ten haemodynamic functions were studied and no differences were found between the frusemide and saline cohorts. As expected urine output was significantly increased in the frusemide treated cohort.
Heart, Lung and Circulation 2012;260:260–66.
This paper from Canada notes that it is now increasingly recognised that uncontrolled hypertension is overlooked in patients with normal office BP (OBP) but high home BP, a phenomenon termed masked hypertension (MH). Their study involved OBP measurement at baseline and after 3 months of valsartan-based therapy in 5636 hypertensive patients who had recorded their home blood pressure monitoring (HBPM) for 7 consecutive days at month 3 using an Omron HEM-711 apparatus. Their findings were that one of five hypertensive patients and more than one of three with controlled OBP will have MH. MH is associated with other cardiovascular risk factors, such as diabetes, and in non diabetics, with male sex, older age and obesity.
Int Med J 2012;42:260-70.
Introduction of reliable and analytically accurate point-of-care devices allows self-testing by the patient in the home setting. Patients can have their test results managed by their health-care provider (self-testing) or they can interpret their INR results, and adjust their own dose of anticoagulant accordingly (self management). This report is a meta-analysis of 11 trials that compared self-monitoring of therapy with conventional testing and medical supervision.
The authors conclude that self-monitoring and self-management of oral coagulation is a safe option for suitable patients of all ages. The very best outcomes were in patients younger than 55 yrs and those with mechanical heart vales. An editorial agrees that self-management should be offered to those with mechanical heart valves but is not enthusiastic about its widespread use. They point out that the advent of several new oral anticoagulants which do not require monitoring may displace warfarin as the anticoagulant of choice.
Lancet 2012;379:322–34 & 292–3.
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