Интересные ссылки

[sense]

То есть подразумевается, что ИПП назначаются пациентам более высокого риска/более тяжелым соматически

[Chevychelov]

Капайте, господа!
ACC: Metabolic Support May Only Mitigate MI
By Crystal Phend, Senior Staff Writer, MedPage Today

Published: March 28, 2012

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco.



Action Points
An infusion of glucose, insulin, and potassium (GIK) to patients on the way to the hospital for acute coronary syndromes won't stop a myocardial infarction but may improve outcomes.
Early administration of GIK saved lives, cutting the risk of cardiac arrest or in-hospital mortality as a secondary endpoint by 52% compared with placebo.


CHICAGO -- An infusion of glucose, insulin, and potassium (GIK) to patients on the way to the hospital for acute coronary syndromes won't stop a myocardial infarction (MI) but may improve outcomes, a clinical trial determined.

The rate of progression to MI wasn't significantly lower with the IV solution compared with placebo (48.7% versus 52.6%, odds ratio 0.88, P=0.28), Harry P. Selker, MD, MSPH, of Tufts Medical Center in Boston, and colleagues found.

However, early administration saved lives, cutting the risk of cardiac arrest or in-hospital mortality as a secondary endpoint by 52% compared with placebo (4.4% versus 8.7%, P=0.01), they reported here at the American College of Cardiology meeting and online in the Journal of the American Medical Association.

Final infarct size was smaller too, covering 2% of the left ventricular mass in the treatment group compared with 10% in the placebo group (P=0.01).

"Risks and side effects rates from GIK are very low, and GIK is inexpensive, potentially available in all communities, and deserves further evaluation in trials for widespread EMS use," Selker said at the late-breaking clinical trial session.

Anything that costs around $50 per IV bag and can save lives on this magnitude is well worth another larger study with better endpoints, likely cardiac arrest, he told reporters at a press conference afterward.

Meanwhile, paramedics might still consider using it, he told MedPage Today.

Despite the fact that the trial failed overall, many cardiologists at the conference were also optimistic that the results would resuscitate this old strategy.

"I think the study is going to revive interest in a therapy that people had thought was clearly not beneficial," Howard C. Bauchner, MD, editor-in-chief of JAMA, said at a press conference after the session.

The idea of GIK for metabolic support during cardiac ischemia was gained some momentum in the 1970s based on animal study results.

The solution provides extra metabolic fuel to help out myocardial cells threatened by ischemia; preserves levels of potassium to protect against arrhythmia; and reduces levels of the free fatty acid that waste oxygen, damage membranes, and contribute to arrhythmia.

While logical as a therapy, the lack of benefit in multiple trials made GIK a dead issue, explained study discussant Bernard Gersh, MD, of the Mayo Clinic in Rochester, Minn.

But those studies typically gave GIK 6 hours after onset of symptoms during or after reperfusion, whereas the critical period of ischemia and the highest mortality from acute coronary syndromes is in the first hour, Selker noted.

The trial in a way vindicated the hypothesis but likely failed due to poor choice of endpoints, Gersh suggested.

"I would not have expected [GIK's mechanisms] to affect the primary endpoint, which is the development of a myocardial infarction," he told attendees. "I would have expected GIK to work through modification of reperfusion injury and myocardial cell division. I would actually have turned the endpoints around."

The IMMEDIATE (Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care) trial included 911 patients with acute ischemia, determined on ECG by paramedics, in 13 cities.

The participants were randomized to receive double-blind treatment with placebo or a solution of 30% glucose, 50U insulin, and 80mEq potassium per liter at a rate of 1.5 ml/kg per hour initiated by paramedics. The GIK dose was confirmed by emergency physicians at the hospital for continued use after patient arrival for a total 12 hours.

Time to initiation of the study drug was a median 90 minutes after symptom onset, and 31% in both groups received the GIK or dummy infusion within 60 minutes.

For the intent-to-treat results, all individual endpoints favored GIK but without reaching statistical significance. Compared with placebo, the risks were:
12% lower for progression to MI (49% versus 53%, P=0.28)
28% lower for 30-day mortality (4% versus 6%, P=0.27)
44% lower for cardiac arrest (4% versus 6%, P=0.08)
38% lower for in-hospital mortality (3% versus 5%, P=0.18)
27% lower for the composite of 30-day mortality or hospitalization for heart failure (6% versus 8%, P=0.24)


Results were similar but suggested a bigger advantage in the patients confirmed to have ST-segment elevation MI, which is the population thought to stand the best chance of a treatment effect.

Gersh and another panel member at the session questioned the magnitude of the effect on cardiac arrest and hospital mortality.

But Selker countered that a halving of that mortality wasn't unreasonable because most deaths occur in the first hour.

In subgroup analyses, the greatest advantage in the composite of cardiac arrest or hospital mortality was with GIK in the first hour after symptom onset (P=0.02).

Risk of elevated potassium over 5.5 mEq/L tended to be higher with GIK (4% versus 2%, P=0.098). Glucose reached over 300 mg/dL in 44% of GIK patients compared with 29% of the placebo group (P=0.02).

It's "back to the future," said conference chair Patrick O'Gara, MD, of Brigham & Women's Hospital in Boston.

"A trial like this might suggest that, in addition to the heparin and the aspirin and nitroglycerin that patients receive by EMS during transport to the hospital, some of them might benefit from an infusion of this type of medication in order to reduce the morbid complications of their heart attack," he said

Selker cautioned that the absolute number of events in the trial was small and that the infarct size findings were based on a subset of 143 patients. Longer term follow up is under way, he noted.

[Chevychelov]

American College of Rheumatology 2012 Recommendations for the Use of
Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee
[Ссылки доступны только зарегистрированным пользователям ]

[cactus1972]

Умеренное употребление алкогольных напитков женщинами не только не вредно, но и полезно, т.к. снижает риск развития инсульта

[Ссылки доступны только зарегистрированным пользователям ]

...the relative risks of stroke were 0.83 (95% confidence interval [CI], 0.75 - 0.92) for women who consumed < 5 g/day, 0.79 (95% CI, 0.70 - 0.90) for 5 to 14.9 g/day, 0.87 (95% CI, 0.72 - 1.05) for 15 to 29.9 g/day, and 1.06 (95% CI, 0.86 - 1.30) for 30 to 45 g/day. Results were similar for ischemic and hemorrhagic stroke.

There are several ways that alcohol might reduce the risk of stroke. Alcohol has components which prevent blood clots and promote HDL cholesterol, which is the good cholesterol.

Однако, авторы предупреждают, что

women who currently do not drink should not start to drink in the belief that this will protect them from stroke.

[cactus1972]

Korzun одобрил(а): и врачам хорошо и женщинам полезно

Да вот, оказывается, не очень-то женщинам алкоголь полезен

[Ссылки доступны только зарегистрированным пользователям ]

A significant increase of the order of 4% in the risk of breast cancer is already present at intakes of up to one alcoholic drink/day

...the relative risk (RR) for breast cancer in light drinkers versus nondrinkers in the 113 studies was 1.04 (95% confidence interval [CI], 1.02 - 1.07). This is a "modest but significant association between light drinking and breast cancer...

А вот определение безопасной дозы

The definition of light drinking in the new analysis was no more than 12.5 g of ethanol per day or 1 drink per day or less.

В общем, как говориццо, либо к умным, либо к красивым

[Korzun]

Сообщение от cactus1972

либо к умным, либо к красивым

Как всегда все дело в дозе.
Но это же многовековая мудрость касающаяся вообще всего:
радикализм (крайние проявления: махровый алкоголизм или воинственная трезвость) - не гуд, а умеренность - форева.

[Korzun]

[Ссылки доступны только зарегистрированным пользователям ]

Многообразный медицинский калькулятор, например:
- сосчитать риск инсульта для выбора варфарина при ФП по шкале CHA2DS2-VASc,
- сосчитать коррегированный QT,
- ИМТ,
- Кому по шкале Глазго,
- шкала алкогольного гепатита Глазго,
- АПГАР
и т.д.

[Igor73]

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960324-9/fulltext?elsca1=ETOC-LANCET&elsca2=email&elsca3=Cardiology


Summary

Background

The relative safety of drug-eluting stents and bare-metal stents, especially with respect to stent thrombosis, continues to be debated. In view of the overall low frequency of stent thrombosis, large sample sizes are needed to accurately estimate treatment differences between stents. We compared the risk of thrombosis between bare-metal and drug-eluting stents.

Methods

For this network meta-analysis, randomised controlled trials comparing different drug-eluting stents or drug-eluting with bare-metal stents currently approved in the USA were identified through Medline, Embase, Cochrane databases, and proceedings of international meetings. Information about study design, inclusion and exclusion criteria, sample characteristics, and clinical outcomes was extracted.

Findings

49 trials including 50 844 patients randomly assigned to treatment groups were analysed. 1-year definite stent thrombosis was significantly lower with cobalt-chromium everolimus eluting stents (CoCr-EES) than with bare-metal stents (odds ratio [OR] 0·23, 95% CI 0·13—0·41). The significant difference in stent thrombosis between CoCr-EES and bare-metal stents was evident as early as 30 days (OR 0·21, 95% CI 0·11—0·42) and was also significant between 31 days and 1 year (OR 0·27, 95% CI 0·08—0·74). CoCr-EES were also associated with significantly lower rates of 1-year definite stent thrombosis compared with paclitaxel-eluting stents (OR 0·28, 95% CI 0·16—0·48), permanent polymer-based sirolimus-eluting stents (OR 0·41, 95% CI 0·24—0·70), phosphorylcholine-based zotarolimus-eluting stents (OR 0·21, 95% CI 0·10—0·44), and Resolute zotarolimus-eluting stents (OR 0·14, 95% CI 0·03—0·47). At 2-year follow-up, CoCr-EES were still associated with significantly lower rates of definite stent thrombosis than were bare-metal (OR 0·35, 95% CI 0·17—0·69) and paclitaxel-eluting stents (OR 0·34, 95% CI 0·19—0·62). No other drug-eluting stent had lower definite thrombosis rates compared with bare-metal stents at 2-year follow-up.

Interpretation

In randomised studies completed to date, CoCr-EES has the lowest rate of stent thrombosis within 2 years of implantation. The finding that CoCr-EES also reduced stent thrombosis compared with bare-metal stents, if confirmed in future randomised trials, represents a paradigm shift.

[cactus1972]

Как ни парадоксально, на мой взгляд, но факт

[Ссылки доступны только зарегистрированным пользователям ]

[Korzun]

Происходит смирение агрессивной медицины с процессами патофизиологии старения через доказательный путь. Этакий призыв к умеренности
Оставить постояную фибрилляцию уже допустимо давно.
Теперь легкий диабет - как часть нормальной старости?
Глюкоза ведь универсальный корм любому страдающему органу и не чета рибоксинам, триметазидинам, ноотропам и гепатопротекторам

[Melnichenko]

Это не столько смирнеие с легким диабетом ( степени тяжести ушли давно) , сколько признание необратимости некоторых процессов ( феномен метболической памяти ) и ухудшения состняи при чрезмерном стремлении к идеалу ( разные цели дб у разных больных ).
Супротив контринсулярных не попрешь гормонов
На самом деле сие никогда не противоречило реальной практике - вряд ли кому либо приходила мысль добиваиться нормогликемии на смертном одре у хронического больного ежели не имел целевых уровней UKPDS гликемии 15 лет ,нелепо достигать их в старости

[Gilarov]

И толстые пациенты с ХСН живут дольше, т. Н. Obesity paradox

[Melnichenko]

И продолжая мысль о смрирении ( скорее принятии факта и угасания юношеского максимализма в эйфории от UKPDS) - исследование касалось впервые выявленных в возрасте 55 плюс - минус 5 лет, но никак не распространялось на 1000000 летних...

[Veronika_val]

Надо еще по странам и расам смотреть. Для японцев может и пол "дринька " хватит. :

[Dr.Vad]

Недавний мета-анализ сравнения риска кровотечения на аспирине и варфарине: отсутствует разница в риске больших кровотечений, имеется тренд повышения риска внутричерепных кровотечений на варфарине, частота малых кровотечений в полтора раза выше на варфарине; повышение риска всех кровотечений на варфарине было замечено среди пациентов до 70 лет (OR 1.71; 95% CI 0.98–2.98), в то время как после 70 лет он отсутствовал.

Background: Warfarin and aspirin (acetylsalicylic acid [ASA]) are the most commonly used anticoagulant and antiplatelet drugs in the treatment of cardiovascular disease.
Objectives: To provide a pooled estimate of the bleeding risk from randomized controlled trials (RCTs) comparing warfarin and ASA at the dose ranges recommended in evidence-based guidelines.Patients/Methods: Ovid MEDLINE, Embase and the Cochrane Library, up to September 2011, were searched for RCTs comparing bleeding rates in adult patients randomized to warfarin, target International Normalized Ratio (INR) 2.0–3.5, and ASA, 50–650 mg daily, with at least 3 months of follow-up. Pooled odds ratios (ORs) and associated 95% confidence intervals (CIs) were calculated with the inverse variance method and the random effects model.
Results: Four thousand four hundred and forty-two abstracts were screened, resulting in eight included studies for final analysis. A pooled estimate derived from the 2904 patients enrolled indicated a trend towards an increase in major bleeding risk in those randomized to warfarin (OR 1.27; 95% CI 0.83–1.94). The pooled OR for intracranial hemorrhage in patients treated with warfarin vs. ASA was 1.64 (95% CI 0.71–3.78), and that for extracranial major bleeding was 1.03 (95% CI 0.61–1.75). Minor bleeding, from a 1748-patient sample, was more common in warfarin patients (OR 1.50; 95% CI 1.13–2.00).
Conclusions: This meta-analysis failed to find a statistically significant difference in major bleeding between warfarin, target INR 2.0–3.5, and ASA, 50–650 mg daily. The trend towards increased bleeding with warfarin appears to be explained by an excess of intracranial bleeding in warfarin patients.

Bleeding risk in randomized controlled trials comparing warfarin and aspirin: a systematic review and meta-analysis.
Warkentin AE, Donadini MP, Spencer FA, Lim W, Crowther M.
J Thromb Haemost. 2012 Apr;10(4):512-20.