Know what the number one cause of death is? Heart disease, in one of its several permutations, fells the majority of us, with the Centers for Disease Control and Prevention citing just shy of 620,000 deaths from heart disease in 2007. Why not more current data? It takes awhile to crunch the numbers, but perhaps electronic medical records will aid that. So in contrast to every other blog post I've ever done, this time I'll talk about two papers related to heart disease Rick and I discuss in this week's podcast. And I'll also ask every physician listener/reader out there to send me an email on whether you'd be interested in a CME accredited version of the podcast. Send that to firstname.lastname@example.org, and thanks!
If you've had a heart attack or myocardial infarction and you take one of a number of nonsteroidal anti-inflammatory medications (NSAIDs) you are at increased risk of death or another MI, as reported in this issue of Circulation. And in spite of abundant evidence for its efficacy, many people with coronary artery disease aren't receiving so-called 'optimal medical therapy,' opting instead for a procedure to open their clogged arteries to the heart. Even those who've already had such a procedure still aren't getting the right meds and other advice. That's in the current issue of JAMA. Let's look at NSAIDs first.
Ibuprofen, diclofenac, naprosen and several other NSAIDs were found to be associated with an increased risk of recurrent MI or death in this cohort of almost 84,000 people who had already had at least one heart attack. The worst of them was diclofenac, associated with an almost 300% increased risk. And risk was seen when people used these medications for as short a time as one week.
Yikes! Nothing like a fairly significant risk with medications available over the counter, and as such, widely perceived as safe. Those who've been paying attention know, of course, that that old standby, acetaminophen, marketed under the brand name Tylenol, can cause liver problems and even death in high doses. We also know that aspirin can cause bleeding problems in those who take too much or are susceptible. Now we can add to the list of risks of self-administered medications death or another heart attack in those who've had one already.
Does this mean we should restrict the use of over the counter pain medications? No, but we should make people as aware as possible that there is no such thing as a free lunch, and ALL medications have a risk/benefit ratio associated with their use.
The second study,'Patterns and Intensity of Medical Therapy in Patients Undergoing Percutaneous Coronary Intervention,' took at look at how often those with coronary artery disease were prescribed optimal medical therapy either before or after stent placement (that's common speak for PCI), either before a large trial called "COURAGE" clearly demonstrated its benefit or after the study results were published. Here's the bad news: optimal medical therapy isn't even close to being used as often as it should be, and even after results of COURAGE have been made available, remains dramatically underutilized.
Yikes again! Optimal medical therapy consists of an anticlotting medication, a beta blocker to reduce blood pressure, and a statin medication to reduce cholesterol. Not too onerous a regimen, but neither physicians nor patients are using it. Why not? Rick and I offer several potential reasons, including our predilection societally to do something to fix things NOW rather than wait for medications to help, but my personal bias is against procedures when at all possible, so I feel these results point to a drastic need to educate both physicians and patients.
Other topics this week include two from Archives of Internal Medicine: Repeat colonoscopy in a Medicare cohort, and physician attitudes toward continuing medical education. Until next week, y'all live well.
The Big Killer,4 Comments