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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) Ph

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 Goldh

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,

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.

Dr. Danielle Scheurer and Joe Elia have a free-form discussion on what’s happened over the past year. Links to those stories (and, sometimes, interviews) are attached here. If you’d like to suggest another, or comment on our selection, drop us a note in the comments field. Discussion-related links (they are all free links): Rivaroxaban Dabigatran Screening for lung cancer with low-dose CT (National Cancer Institute announcement) Clinical Conversations interview with a principal investigator on the lung-cancer screening trial Annals of Internal Medicine study warning against false-positive findings with CT screening Emphasizing chest compressions in CPR (Physician’s First Watch summary) Guidelines for clinicians performing CPR (from Circulation) Disparate views on PCI’s benefits between patients and their physicians — after informed consent U.S. lags behind other developed countries in health measures (Commonwealth Fund report summary) National Healthcare Quality Report 2009 The post Podcast 111: A look bac

This week’s guest, Dr. Sripal Bangalore, finds no evidence that use of the standard anti-hypertensive drugs increases risks for cancer. His meta-analysis did find, however, an indication that ARBs and ACE inhibitors, when used in combination, increase risks modestly. Even with the short follow-up, Bangalore says clinicians should find reassurance in the results. Listen in. Interview-related links: Physician’s First Watch coverage of the Lancet Oncology meta-analysis Lancet Oncology abstract FDA MedWatch statement (July 2010) concerning ongoing investigation of ARBs and cancer risk First Watch coverage of earlier Lancet Oncology meta-analysis (June 2010) raising concerns The post Podcast 110: ARBs (and anti-hypertensives, generally) pose no measurable cancer risk, meta-analysis shows. first appeared on Clinical Conversations.

We’ve got Dr. Harlan Krumholz, editor of Journal Watch Cardiology and CardioExchange, to guide us through a week’s worth of the top research presented at the American Heart Association in Chicago. Interview-related links (in the order we discuss them in the interview): CardioExchange (worth checking out — it’s an experiment in the clinical use of social media) The anacetrapib study Kidney denervation Comparing rivaroxaban versus warfarin Adding cardiac resynch function to ICDs Remote telemonitoring in heart failure The post Podcast 109: An overview of the American Heart Association meeting, with cardiologist Harlan Krumholz first appeared on Clinical Conversations.

We talk with Dr. Denise Aberle, a principal investigator on the CT-for-lung-cancer-screening trial that the National Cancer Institute stopped last week. NCI stopped the trial when the trial’s monitoring committee found a 20% decrease in lung cancer deaths among those randomized to CT screening. Listen in for a fascinating look at what happens when trials stop — and most especially for the implications of this one. Please make your comments here on the website. Interview-related links: Radiology article describing the study News release from the National Cancer Institute The post Podcast 108: CT screening for lung cancer first appeared on Clinical Conversations.

Our conversation is with Dr. Patricia Dykes of Boston’s Partners HealthCare. She’s first author on a paper published in JAMA earlier this week. In her study of fall prevention in hospitals, she and her team randomized eight medical units in four Boston-area hospitals either to their usual standards of fall prevention or to use of the “fall-prevention toolkit” — an intervention customized for each patient. The results are encouraging. Interview-related links: First Watch coverage (free) The study abstract in JAMA (free) Dr. Dykes’ email address News-related links: Radiology article on CT screening for lung cancer (free) National Cancer Institute’s news release on the CT study Duloxetine approved for chronic musculoskeletal pain BMJ article on vitamin E’s stroke hazards (free) (advertisement) QuantiaMD & Journal Watch National Case Challenge – $2500 Grand Prize Entering is easy and takes about 15 minutes – simply provide basic information about your case using our one-page entry form.   Submissions

OK, now what can be done to control hypertension among African American men? What about recruiting barbershops to put a shoulder to the wheel? They’re community centers, trusted sources of gossip and advice, and places of relaxation. In Texas, a group of researchers undertook a randomized trial in black-owned barbershops in which barbers took blood pressures and made referrals to clinicians when necessary. Listen in on how it went. Interview-related link: Physician’s First Watch coverage News-related links: ACIP recommends vaccination boosters in two areas Asking after dad’s family history of breast and ovarian cancer (advertisement) QuantiaMD & Journal Watch National Case Challenge – $2500 Grand Prize Entering is easy and takes about 15 minutes – simply provide basic information about your case using our one-page entry form.   Submissions are due by November 8, 2010.  Finalists will be chosen by the editorial boards of QuantiaMD and Journal Watch.  We will work with finalists to produce and publ

In the face of scheduling problems we’ve had to postpone this week’s interview and use, instead, one from early this summer. It’s on NSAIDs, and if you missed it, it’s worth a listen. If you didn’t miss it, then join us again next week, but give a listen to the news round-up before you head off to rake leaves…. The pace of suggestions and comments has quickened, and I’m grateful. Please keep them coming to jelia@jwatch.org. Interview-related link: First Watch coverage of the NSAIDs article from June 9, 2010 News-related links: Stroke  guidelines as published in Stroke First Watch summary of the guidelines plus links to hypertension & diabetes care standards FDA alert on prostate cancer drugs used for androgen deprivation therapy NEJM paper on dabigatran from August 2009 *  *  * (advertisement) QuantiaMD & Journal Watch National Case Challenge – $2500 Grand Prize Entering is easy and takes about 15 minutes – simply provide basic information about your case using our one-page entry form.   Submis

We welcome Dr. Danielle Bowen Scheurer to our conversational team this week She’s a hospitalist at the Medical University of South Carolina and an associate editor of Physician’s First Watch. Our guest is Dr. Deepak Bhatt, who has just published some reassuring results on omeprazole’s putative interaction with clopidogrel in the New England Journal of Medicine. If you’d like to suggest topics or ways to improve this podcast, we’re all ears. Drop me a line at jelia@jwatch.org — thank you. Interview-related link: New England Journal of Medicine article (free) News-related links: Vaccine matchup looks good — MMWR article (free) Low Apgar scores and cerebral palsy risk — BMJ article (free) Screening survivors of childhood cancer — Annals abstract (free) COG screening guidelines (free) The post Podcast 104: Reassurance on clopidogrel and omeprazole. first appeared on Clinical Conversations.

Welcome back. We take a look this week at a study from Iceland that looks at whether estimated glomerular filtration rates have a role in estimating cardiovascular risk. Our interview is with Cambridge University’s Dr. Emanuele Di Angelantonio. Your comments are welcome, both here and to my email address: jelia@jwatch.org. Interview-related links: BMJ study (free) BMJ meta-analysis (free) BMJ editorial (subscription needed) News-related links: ADHD story in Physician’s First Watch Archives of Disease in Childhood (abstract) MMWR (free) Annals of Family Medicine (free full text) The post Podcast 103: eGFR and cardiovascular risk assessment first appeared on Clinical Conversations.

Prof. Martin Dennis chats with us about his latest trial, comparing the utility of thigh- versus below-knee-length stockings for patients immobilized after stroke. The latest results show the superiority of thigh-length stockings, but at the further risk of skin breaks in these vulnerable patients. Taken together with the results of his earlier work, at the very least the use of below-knee-length compression stockings — now widely used in patients undergoing surgery — must be called into question. Interview-related links: Clinical Conversation’s earlier interview with Prof. Dennis. Full text of the latest trial in Annals of Internal Medicine (free) News-related links: Avandia (rosiglitazone) restricted in Europe and the U.S. Mammography’s modest contribution to lowering breast cancer mortality New MS drug, fingolimod, approved by FDA The post Podcast 102: Short compression stockings would seem to have no further role clinically. first appeared on Clinical Conversations.