Journal Scan 3 – Dr Iqbal Malik

How can you detect a heart attack during coronary bypass (CABG) surgery?

This study from 2011 did an interesting piece of work comparing blood markers, including troponins, and MRI scans to hunt for areas of heart attack after CABG. A single troponin marker at 24 hours greater than 6.6 micg/l predicted an infarction (heart attack) on MRI scan. If no infarction occurred, the troponin rise was early, within 6 hours, not at 24 hours.
Although only in 40 patients, perhaps we should be assessing the 24 hour troponin level to diagnose a heart attack after CABG.

Pregnancy and high blood pressure. What’s the risk?

This excellent study looks to assess the risk from angiotensin converting enzyme inhibitors in pregnancy. This class of drug are not recommended in later pregnancy as the baby can be affected, but if they also cause harm in the 1st third of pregnancy, they should not be used in any woman of childbearing age! This study suggests the risk is related to the hypertension itself, and not any specific drug. With the time bomb of obesity and diabetes, the rates of hypertension in the young are rising. About 1.6% of normal pregnancies had babies with cardiac abnormalities. This rose to 2.5-3% if the mother had hypertension, whether treated or not.
Blood pressure problems in pregnancy need to be carefully assessed.

Statins: a panacea for heart attack reduction, but is diabetes risk increased?

There is a huge amount of evidence that people that have had heart attacks or stroke, or are at moderate to high risk of them, benefit from statins. This editorial piece in the Bmj reflected on the increasing data that there is a small increase in the risk of developing diabetes. If 255 patients are treated for 4 years, one will develop diabetes. It may be that only the highest doses of statins have this effect. But these doses are usually used in those at highest vascular risk, when the overall benefit of statins is proven.
I would say that these data, from analysis of data from all the statin trials, won’t change my recommendation for statin therapy in most people at even moderate cardiovascular risk. Routine assessment of diabetes risk, with HbA1C levels for example, before and after statins start, sounds sensible.

Endocarditis. A deadly infection

You can get heart valve infections even on a normal valve, but it is more likely on an abnormal valve. When to operate and how to predict outcome is a real challenge. This study suggests that heart failure resistant to diuretics, staphylococcus infection, and abscess formation predicted poor outcome in left heart endocarditis. The linked paper shows that if you had none of the above, 30% got valve replacement or died. If you had any one of them, this rose to 60%, if two then 80% and all three then 100%.
Of interest also was that the old idea that if you abused IV drugs, and got endocarditis, it was likely to be right heart, is wrong. Most had left heart disease and early use of transoesophageal echocardiography (TOE) was essential.
In addition, the linked editorial states clearly that ” waiting for antibiotics to work” is not a good option.
The timing is being tested in a trial I eagerly await –ENDOVAL.

Posted on 27 April 2012
Author: LCC
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