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Bypass surgery upstages stenting for patients with diabetes and multivessel coronary artery disease

MD-FM Thursday November 8, 2012

Sarah :
MD FM — Medical News from around the the world with Peter Goodwin

PETER: Hello, and to begin with, fresh news from the American Heart Association’s annual meeting in Los Angeles: bypass surgery is clearly better than stenting for diabetics with multivessel coronary artery disease.

SARAH: These are the findings of the FREEDOM trial, which included 2000 diabetics with multivessel CAD, randomized to either one of the procedures. At 5 year follow up, they looked at the combination endpoint of myocardial infarction, stroke and death from all causes: 26% of patients undergoing PCI with drug eluting stents had an event, compared to 18% in the bypass group –a relative difference of about 35%.

Bob-Valentin: “Perhaps one of the most striking data that came out is that any subgroup: men vs. women, race -black vs. white --countries, SYNTAX score, which is so important --didn’t make a difference: in all these subgroups CABG was superior, and with each of the variables of the subgroups. So the results were so clear that in a way I think this is going to change practice.”

SARAH: That was Valentin Fuster, from New York, who spoke to us right after presenting his results in LA earlier this week. He had this to add:

Bob-Valentin: “40% of the patients declined to enter the study because they preferred PCI, because you don’t open the chest. I think today we have to be much more cautious, and try to convince these groups to undergo bypass surgery .”

SARAH: Valentin Fuster, from New York. Experts such Alice Jacobs from Boston Medical Center, who did not participate in the trial, agreed with this interpretation for the current practice. Concerning the future, here’s what she added:

Bob-Jacob: “Anything that we now discover to treat discrete lesions probably won’t impact these results. That said --we need to think about the fact that the reliable detection and potential prophylactic treatment of the vulnerable plaque may not be that far away.”

SARAH: Pr. Jacobs, from Boston.

PETER: More news straight from the AHA meeting: An investigational fully human monoclonal anti-PCSK9 antibody was able to reduce LDL cholesterol by over 50 % in statin-intolerant patients –a difficult-to-treat population…
SARAH: Yes, so this was a 12-week, randomized, double-blind, placebo- and ezetimibe-controlled study entitled GAUSS. The team assessed the efficacy of different doses of the PCSK9 antibody given subcutaneously, and the 51% decrease was obtained in the subgroup receiving the highest dose of PCSK9 antibody: 420 mg.
And when the antibody was combined with ezetimibe -- a drug that blocks cholesterol absorption –it reduced LDL-cholesterol by 63%, compared to 15% when using ezetimibe alone.

BOB STEIN: “This drug looks like it provides at least a very promising alternative, it’s going to require a lot larger confirmatory studies and of course long term safety data, just as we did when we developed statins.”

SARAH: That was investigator Evan Stein, director of the metabolic and atherosclerosis research center in Cincinatti, talking to us in Los Angeles. Peter Wilson, from Emory University in Atlanta Georgia, who did not participate in the trial, agreed with Pr. Stein’s enthusiasm:

Bob WILSON: “To get a 40 to 50 per cent creates a new excitement I would say for opportunity, but it’s going to be 2 to 4 years probably before these get through their clinical trials.”

SARAH: That was Pr. Wilson, from Atlanta.

PETER: Aspirin is a good option for the extended treatment of patients having experienced a first episode of venous thromboembolism and who are about to terminate their initial anticoagulant treatment. While aspirin did not significantly reduce the rate of VTE recurrence, it did reduce the rate of major vascular events, with improved net clinical benefits. These are the finding of the ASPIRE study, presented during the AHA meeting.

PETER: For every life saved thanks to breast cancer screening, approximately three women are said to be overdiagnosed…

SARAH: Yes, these are the conclusions drawn by a panel of 6 independent experts who analyzed the most robust pivotal randomized trials available in the literature to estimate the benefits and harm of regular breast cancer screening mammography. Listen to the interpretation of these findings by David Cameron, one of the experts of the panel:
BOB-CAMERON: “I think it means 2 important things: firstly, we need to make it clear to women that breast cancer screening is worth doing, because it means fewer women dying from breast cancer, but the individual women need to be aware that there is this risk that they could have an overdiagnosed cancer, and at the moment we have no way of telling which cancers are overdiagnosed, so they all need to be treated --women need to be aware of that. I think the second thing is for the medical research community: we need to be doing more research to try and establish how we may be able to tell that a cancer found through screening is an over diagnosed one, for example to try and understand more of the actual biology of the cancer, the signals in the cancer that suggest it may not go on to cause problems. ”

SARAH: That was Pr. Cameron, chair of oncology at the University of Edinburgh in the UK.


PETER: Individuals with smaller amygdalas may be more vulnerable to post-traumatic stress disorder…

SARAH: This is what experts hypothesized after observing, in a study involving 200 war veterans, that the amygdala volume of participants with PTSD was, on average, smaller than that of veterans without PTSD.

PETER: The amygdala’s relevance to PTSD has been talked about quite a bit because of its very central role in fear processing, but previous results had been equivocal..

SARAH: Yes but here: the team measured amygdala volumes using state of the art imaging techniques and computer algorithms. They also showed that amygdala volumes were not correlated with trauma load or PTSD chronicity, which led them to hypothesize that this smaller size preceded trauma exposure and could thus represent a vulnerability factor for PTSD. The next step will be to confirm this hypothesis.

BOB-MOREY: “It’s still too early to probably use this kind of information in a clinical setting --either for prevention or for treatment --but I think that there is this idea that some people are more vulnerable, some people are more resilient to PTSD, and that amygdala volume may be just one of several factors, several biological markers that can help us understand or maybe predict who is vulnerable”

SARAH: That was Rajendra Morey, from Durham VA Medical Center in North Carolina, lead author of Archives of General Psychiatry study.

BREVE 1 Sur fond musical

PETER: Finally, in brief: in patients with autosomal dominant polycystic kidney disease, a V2-receptor antagonist, Tolvaptan, slowed the increase in total kidney volume and the decline in kidney function over a 3-year period. However, it was associated with a higher discontinuation rate compared to placebo, owing to adverse events. These are the findings of a phase 3 trial published in the NEJM.

And …..
Topical ivermectin was well tolerated and much more efficacious than placebo to eradicate headlice in children as young as 6 months, according to a NEJM study. However, an accompanying editorial suggested that, until good comparative-effectiveness research is led vs. current options, ivermectin should only be used as a last resort.

That's all from MDFM for now. We'll be back next week


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Best of Science in Nutrition 2013: Yogurt for a healthier diet (EB & IUNS 2013)
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