Friday, June 17, 2005

Review: Chronic Stable Angina

The NEJM has a very nice review article titled Chronic Stable Angina.
"It is useful to classify therapeutic drugs into two categories: antianginal (anti-ischemic) agents and vasculoprotective agents. Although medications for angina are widely used, therapy to slow the progression of coronary artery disease, to induce the stabilization of plaque, or to do both is a newer concept and these forms of treatment are underprescribed."

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Medical Simulation Weblog

I found a neat new weblog called SimBlog. Associated with the Society for Medical Simulation, it appears to be edited by Jeff Taekman, formerly of Penn State and the person I came to Hershey to work with. Jeff had moved to Duke by the time I arrived, and is now the Associate Dean for Technology in Education there.



Saturday, June 11, 2005

NEJM -- Two-Years after Endovascular Repair of Abdominal Aortic Aneurysms

Very interesting Dutch study on Two-Year Outcomes after Conventional or Endovascular Repair of Abdominal Aortic Aneurysms in the NEJM. This is the first study to look at prolonged survival (2 years) after placing a tube stent into a dilated abdominal aorta (aneurysm) to prevent rupture. We know that early survival is better with the stent vs. open repair. But what about after the first month? This study shows that after two years, the survival is about the same:

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" The cumulative rates of aneurysm-related death were 5.7 percent for open repair and 2.1 percent for endovascular repair. This advantage of endovascular repair over open repair was entirely accounted for by events occurring in the perioperative period, with no significant difference in subsequent aneurysm-related mortality. "

To try to explain this, the authors discuss the following possibilities:

"There may be two possible explanations for the convergence of survival curves in our study. One is that patients who have survived the stress of open repair may be somewhat less likely to die in the first few months after surgery than patients who have undergone endovascular repair, since the latter group has not been subjected to a conventional surgical procedure.
...[snip]...
Another possible explanation for the convergence of survival curves is the failure of endovascular repair to prevent rupture of the aneurysm."

I wonder about a third possibility: did patients having an open repair make lifestyle change that those having the less stressful endovascular repair did not? I ask because one of the frustrations in taking care of patients with vascular disease is the extent to which they do NOT change their eating or smoking habits and so need to come back for yet another procedure at yet another time. The study lists baseline characteristics (55% smoked in the open group and 64% smoked in the endovascular repair group. Half in each group had hyperlipidemia), but no characteristics are given at the two year point. Can the lack of survival advantage after endovascular repair be explained by differences in rates of smoking, hyperlipidemia, and other risk factors at two years?

And thanks to the power of Google, I've sent the lead author an e-mail with just this question!

8: 00 A.M., the lead author writes back:

"We haven't studied that in this 2-year analysis but it is part of our long-term study."

Malpractice Insurance for Bariatric Surgeons Increasing

Other Perils of Overweight - New York Times:

" But after several years in which the surgery was seen as the last best hope by many obese people, a growing array of scientific data shows that the risks are greater than patients realized. One new study reported that almost one in 5 patients had complications after surgery. For one in 20 patients, the complications were serious, including heart attacks and strokes. Another recent study said the mortality rate for the most common type of bariatric surgery, gastric bypass, was one in 200 - a rate higher than for coronary angioplasty, which opens blocked heart vessels.

For thousands of patients, the weight-loss surgery has eliminated debilitating diseases and improved the quality of life. But the threat of malpractice lawsuits against doctors and hospitals, as well as the reluctance of health plans to cover the surgery costs, is creating difficulties for people now seeking treatment. "

The article points to an Annals of Internal Medicine article titled Meta-Analysis: Surgical Treatment of Obesity (Annals is another one of those nice free full-text journals).

[Via Common Good]

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