Heart 2012; 98; pg 377-383
Holme et al
How do you follow aortic valve narrowing? Who is at risk for death and should be followed more closely? Several scores have been used to predict surgical operative risk, including euroscore, the STS score and the UK Heart Valve Score (ambler score). There are no good scores to predict who needs surgery, however. Outcome is worse if the patient is older, the valve is already very narrow, or the narrowing is rapidly getting worse. This paper tries to look at factors that can predict who, with moderate aortic stenosis, can expect to go worse. The baseline annual risk for their population was about 1.35% death rate per year. The moderate aortic stenosis patient averaged 2%. This is despite the fact that those with known coronary disease or diabetes were excluded. Thus, the valve disease itself was a moderate risk factor for death!
To improve discrimination, they added heart rate, C- reactive protein (inflammation), bilirubin, and Left Ventircular Mass Index to age, gender and smoking. It works, but I am not sure it will come into general use.
However, it does make the case for assessing patients with moderate aortic valve narrowing regularly, and carefully.
Heart 2012, 98, pg370-376
Watt et al
This interesting paper looks at the cost effectiveness of transcatheter aortic valve intervention.(TAVI) in patients I eligible for surgery, 1 year death rates are up to 50%. In the PARTNER trial this was reduced to 30% by TAVI. This paper by Watt et al. suggests that the treatment is likely to be very cost effective for the NHS. The only caveat is that the patient would, apart from the aortic stenosis, have nothing stopping them living 3-4 years. Those with other huge medical problems may well not get clinical benefit, and the NHS would not get a cost effective treatment.
CLOSURE-1 trial. More questions than answers. The question is easy. Does closing a small hole in the heart (a PFO) reduce recurrent stroke risk in patients who have no other obvious cause of (cryptogenic) stroke? The problem is that the trial suggests no difference in outcome with or without closure, but with what appears to be a low risk population, lots of closures being done outside of the trial but few within it, and with a higher rate of complications that might be expected. In addition, there was a fairly high rate or residual shunting, meaning the hole was not fully closed. The final decision in the individual patient still has to be with all the clinical information to hand, and in liaison between the cardiologist and neurologist.
Lietzman and kurth
Fried food is not bad for you!
This extraordinary statement comes out of the editorial published on the BMJ. It turns out that the “self-evident truth” that eating fried food will give you a heart attack, is not evidence based. Some studies do show that high fried food intake can produce a small increase in heart attacks, but a recent large study suggests no such link. Almost certainly the type of oil used is important. A diet of “deep-fried Mars bars” is unlikely to be specifically tested but the recent study from Spain used mainly olive oil for frying. So the message is to eat in moderation, and if you are to fry food, perhaps use olive oil.
Betablockers in COPD
Give your patients with Chronic Pulmonary Disease Beta-blockers. Don’t be scared of doing this. Cardiovascular mortality goes down, but more surprisingly, so does risk from the lung disease itself. Any COPD patient with heart disease should be on these drugs, and those without should now be considered for this therapy whilst we await a randomised trial.
Come and see a specialist who can go through the evidence with you…