JJ竞技入口

Routine stress testing after PCI

If I ever need a percutaneous coronary intervention (PCI) for coronary artery disease, I think I'd be pleased at the offer of a stress test a year later to make sure everything was tickety-boo. Unfortunately, although this might make me more likely to have another angiogram or further revascularisation, it doesn’t seem to make any difference to the chances of me dying, having a myocardial infarction, or being admitted to hospital for unstable angina in the following year. That’s according to a randomised controlled trial of 1706 high risk patients undergoing PCI who were allocated to usual care or a stress test (nuclear stress testing, exercise electrocardiography, or stress echocardiography) a year later. The authors argue that the study demonstrates the benefits of a “less is more” approach: “if more invasive strategies or testing are performed less frequently, it will result in better patient outcomes,” they say.

N Engl J Med doi: 10.1056/NEJMoa2208335

Who wants a brew?

Coffee drinking health stories seem to get all the attention, so here’s something for those who prefer a nice cup of tea. A prospective cohort study of almost 500 000 people from the UK Biobank has found a small association between tea drinking and reduced all-cause mortality risk over an 11 year follow-up. Even heavy tea drinkers seem to do well: relative to no tea drinking, the hazard ratio of drinking 10 or more cups of tea per day was 0.89 (95% confidence interval 0.84 to 0.95). Better put the kettle on.

Ann Intern Med doi: 10.7326/M22-0041

Will a medical scribe make you more efficient?

One of the things I’ve always wished for (safe in the knowledge that it’ll never happen) is a medical scribe: if only there was someone here with me who could document the consultation, write those referral letters, and maybe even reply to some emails, I’d be free to see more patients and reach the holy grail of unused appointment slots and a mid-morning coffee break.

Rudely awakening me from this dream is a study from a hospital in Oregon, where scribes are available to physicians at their request. They found that the time from clinician encounter to signing the medical record for that encounter was longer for physicians using scribes, and being allocated a scribe didn’t reduce medical record closure times. But I’m not going to give up on my dream so easily: this was a different setting, using endpoints that don’t tell the whole story, and with various possible confounders that could account for the results.

JAMA doi: 10.1001/jama.2022.13558

State of GRACE 2.0

There are so many risk scoring systems in use these days that it’s hard to keep up with their various pros and cons. For patients diagnosed with unstable angina or a non-ST-elevation myocardial infarction, NICE recommends GRACE (Global Registry of Acute Cardiac Events) as an example of an established risk scoring system that predicts six month mortality and which can be used to guide management.

A new evaluation of the GRACE 2.0 score in over 400 000 consecutive patients with non-ST-elevation acute coronary syndrome in the UK and Switzerland finds that it doesn’t perform as well in female patients compared with male patients. Researchers found an “underestimation of in-hospital mortality risk in female patients, favouring their incorrect stratification into the low-to-intermediate risk group (GRACE risk ≤3%) in which the score indicates to withhold early invasive treatment.” The redeveloped machine learning based GRACE 3.0 has, say the authors, corrected this and now “shows excellent discrimination and good calibration.”

Lancet doi: 10.1016/S0140-6736(22)01483-0

SGLT2 inhibitor impact for any severity of heart failure

This new meta-analysis of two trials of SGLT2 inhibitors in people with heart failure with mildly reduced or preserved ejection fractions gives them a big thumbs up as “foundational therapy for heart failure, irrespective of ejection fraction or care setting.” It found reduced risks of cardiovascular death, first hospital admission, and all-cause mortality (hazard ratios of 0.87, 0.72, and 0.92, respectively). Although the analysis is unfunded, the declaration of interests statement for the study comes in at 622 words (nearly as long as this whole page), and there are question marks over the generalisability of the studies included in the meta-analysis, where women were under-represented and only 3.4% of the participants were black.

Lancet doi: 10.1016/S0140-6736(22)01429-5