Clinical Conversations

Guidelines warn about using NSAIDs after myocardial infarction, and a 10-year look-back study from Denmark shows that the warning should be even louder. Whereas current AHA guidelines advise using NSAIDs after MI for the briefest possible time, the Danish study, published last week in Circulation, finds that the risks for death and reinfarction begin within the first week with some NSAIDs, and continue throughout treatment. Diclofenac is especially risky in this context.
Interview-related links:
Circulation abstract (free)
AHA scientific statement on NSAIDs from 2007 (free)
The post Podcast 121: NSAIDs Unsafe at Any Dose after MI first appeared on Clinical Conversations.

European researchers say they’ve got the data to show that restricting salt in the general population is a bad mistake. By implication, the U.S. dietary salt guidelines are plainly wrong.
How did they do this? They followed 3700 subjects for roughly 8 years, having first measured their 24-hour urinary sodium excretion. Their data show that lower salt intake leads to higher cardiovascular mortality and that increasing levels of salt intake are not associated with an increased incidence of hypertension.
The researchers are defiant in the face of criticism, challenging the skeptics to come up with their own data.
The results seem poised to change our assumptions — if not our dietary habits.
Interview-related links:
JAMA abstract
New York Times coverage
The post Podcast 120: Pass the salt! first appeared on Clinical Conversations.

Most clinicians, when asked, say they will routinely recommend calcium supplements for their postmenopausal patients. A meta-analysis from BMJ shows that this well-intentioned advice seems to lead to a moderate increase in cardiovascular risk in these women.
We talk with Prof. Ian Reid, whose re-analysis of Women’s Health Initiative data confirms earlier work he’d done.  Listen in.
Interview-related links:
BMJ paper
BMJ editorial
Earlier meta-analysis from Reid’s group
The post Podcast 119: Calcium supplements and risk first appeared on Clinical Conversations.

Two authors of a JAMA study published earlier this week discuss how prescribing patterns for opioids figured in the rates of unintentional overdose. The work was done using data from Veterans Administration records. Briefly, they found that the risk for overdose was directly related to the maximal dose prescribed, however, patients who received only “as needed” prescriptions as opposed to regular daily amounts were at higher risk for overdose.
The findings have some lessons for all clinicians. Listen in to our 10-minute Clinical Conversation.
If you have suggestions, please leave a comment here — they’re all appreciated.
Interview-related link:
JAMA abstract (free)
The post Podcast 118: Opioid prescribing patterns and accidental overdoses first appeared on Clinical Conversations.

Statins, according to a 2010 meta-analysis in Lancet, are associated with a slightly increased risk for new-onset type 2 diabetes. One, atorvastatin (marketed as Lipitor), was underrepresented in that analysis. Researchers, along with the manufacturer, decided to have a look at data from three trials to see whether atorvastatin also conferred that risk. And, indeed they found that the risk was there — most especially in the SPARCL trial, which compared high-dose atorvastatin with placebo.
Our interview is with the first author of that later analysis, Dr. David D. Waters, of UCSF. His paper appeared earlier this week in the Journal of the American College of Cardiology.
Interview-related links:
JACC abstract (free)
Physician’s First Watch coverage of the JACC paper
Lancet (2010) abstract (free)
Physician’s First Watch coverage of the Lancet paper
The post Podcast 117: Atorvastatin and new-onset diabetes first appeared on Clinical Conversations.

Troponin I levels can now be measured much more accurately and assays have a greater sensitivity. In Edinburgh, the diagnostic level for acute coronary syndrome was lowered from 0.20 ng/mL to 0.05. As a result, when patients presented with suspected ACS they were more likely to be diagnosed — and a year later were more likely be alive and without recurrent infarction.
How do we know this? Because as the more sensitive test was first being introduced, the lab continued to report the old threshold level for six months. That group of patients with lower (yet not reportable) levels than 0.20 ng/mL fared much worse than those with similar troponin results that were reported as being above the threshold during the implementation phase.
Is this just a recipe for overdiagnosis, or should your institution be adjusting its diagnostic threshold?
We have a lively conversation with Dr. Nicholas Mills, the first author of a paper describing all this in JAMA this week.
Interview-related links:
JAMA paper (free abstract)
Physician’s First Watch coverage (free)
The post Podcast 116: What do more sensitive troponin measurements mean for diagnosing ACS? first appeared on Clinical Conversations.

Clinical Conversations, in a collaboration with CardioExchange, has interviewed two expert working clinicians on how best to use dabigatran — a drug poised to supplant warfarin in the prevention of stroke and systemic embolism in patients with atrial fibrillation.
The wide ranging discussion with Drs. Elaine Hylek and Samuel Goldhaber  includes sections on who should be on this new anticoagulant, management of the drug around surgical procedures, and promoting adherence, among others.
CardioExchange (http://www.cardioexchange.org/) is an experiment in clinical community-building, sharing information from both Journal Watch and the New England Journal of Medicine. If you’re interested in matters of the heart you should really give it a look.
Related links for this podcast:
The CardioExchange web site
Guidelines from the ACC, AHA on using dabigatran, published in Circulation
FDA approval of dabigatran
The post Podcast 115: Talking about the real-world use of dabigatran with Drs. Elaine Hylek and Samuel Goldhaber first appeared on Clinical Conversations.

We think you’ll find this of interest. The American Heart Association last month issued revised guidelines for preventing cardiovascular disease in women.
The change that hits you right off is the title’s shift from “Evidence-Based” to “Effectiveness-Based,” emphasizing the writing committee’s belief that the way things go in clinical trials doesn’t always hold in the more chaotic environment of daily practice.
Also of note is the fact that the committee wants clinicians to take women’s reproductive histories into account (they say, interestingly, that pre-eclampsia may be taken as an indicator of underlying inflammatory processes — a kind of proxy for a failed stress test, if you will). And depression, in their view, may be a signal of vulnerability to unhealthy lifestyle choices and an indicator of how adherent to treatment the patient will be, and so a screening for that condition is in order among women presenting with cardiovascular disease.
Join our conversation with the chair of the writing committee, Dr. Lori Mosca.
Interview-related links:
The new guidelines in Circulation (free)
Physician’s First Watch summary (free)
The post Podcast 114: Guidelines for preventing cardiovascular disease in women first appeared on Clinical Conversations.

The SSRI escitalopram beat out a placebo in ameliorating the frequency and severity of hot flashes in menopausal women. Would cheaper SSRIs also do the trick? We talk with the first author of the JAMA paper.
Interview-related links:
JAMA paper (free abstract)
Physician’s First Watch summary
The post Podcast 113: Hot flashes and escitalopram first appeared on Clinical Conversations.

The Infectious Diseases Society of American last week issued clinical practice guidelines on dealing with methicillin-resistant S. aureus infection. We interview the principal author of those guidelines, Dr. Catherine Liu of the University of California, San Francisco.
Dr. Liu responds to the criticism leveled earlier this week against all IDSA guidelines, for their apparent lack of high-level evidence to back their recommendations.
Listen in.  If you have a comment, please leave it here and we’ll post it quickly.
Links related to the interview:
IDSA guidelines in Clinical Infectious Diseases (free)
Archives of Internal Medicine paper criticizing IDSA guidelines in general (free abstract)
Archives of Internal Medicine editorial on the criticism (not free, but worth reading)
The post Podcast 112: MRSA guidelines from IDSA first appeared on Clinical Conversations.