Heart failure, meniscal tears and BP

Too busy to catch up on the latest research? Let Dr Honor Merriman update you on recent papers.

Digitalis in AF
Heart 2008; 94: 191-6
The efficacy of digitalis in heart failure has been recognised for over 20 years and its safety in patients with heart failure has been demonstrated in many clinical trials. As an inotropic agent digitalis has an obvious benefit in heart failure. In patients with fast AF the slowing of the ventricular rate is welcome but an inotropic effect may not be needed.

This study looked at the effect of digitalis compared with placebo in patients with AF. Correction was made for other factors which might have influenced the outcome. It was found that digitalis users had a greater mortality risk than non-users.

The authors point out that the study did not randomise for digitalis use, but in the absence of this data, as yet, the risk is worth considering when choosing treatment for patients with AF.

Women less likely to be offered knee replacements
CMAJ 2008; 178 (6)
It is already known that women are less likely than men to receive lipid-lowering medication after an MI, receive kidney dialysis, be admitted to an intensive care unit, undergo cardiac catheterisation, or renal transplantation. Might this also be true for total knee replacement?

This study suggests that this is another case of male patients being more likely to be offered treatment; in the case of orthopaedic consultants, 22 times more likely. Primary care doctors were only twice as likely. When surgery is such a good solution for osteoarthritis pain why do women miss out?

The authors refer to 'unconscious and ubiquitous social stereotyping that affects our behaviour'. Perhaps we should be aware of this and avoid it.

How best to detect meniscal tears?
Clin Rehabil 2008; 22: 143-61
Clinical examination of the knee to detect a meniscal tear is usually done by using the McMurray test or the Apley test. The McMurray test has a less than 60 per cent sensitivity and specificity. The Apley grind test is similarly not very sensitive or specific.

Another test (Thessaly) has over 90 per cent sensitivity and specificity but was used on a smaller sample of patients.

These tests were compared with joint line tenderness and the latter was found to be the most reliable test.

So when assessing patients in the surgery joint line tenderness is recommended. In future, the Thessaly test may be best after it has been further evaluated.

Bare-armed BP
CMAJ 2008; 178 (5)
Accurate BP measurement is important and current guidelines have set standards for cuff size, arm position, timing of the reading and the need to measure over a bare arm.

When recommending rep- eat readings through the day bare arms may not be feasible. A comparison of readings taken in patients using an automated machine showed only small and insignificant differences in readings taken twice on covered and uncovered arms.

It is often the simple low-tech research that makes a difference to day to day clinical practice. This is one tip I intend to put into effect from now on.

Bisphosphonates, AF and atrial flutter
BMJ 2008 doi: 10.1136/bmj.39507.551644.BE
There has been concern (based on previous studies) that patients on bisphosphonates might be more at risk of atrial arrhythmias.

Despite their efficacy, many patients who would benefit from these drugs do not, perhaps because of doubts about safety. The combination of AF and osteoporosis would be dangerous for some elderly patients.

This Danish study compared the prevalence of AF and atrial fluter in those taking bisphosphonates and placebo. There was no increase in atrial arrhythmias in the bisphosphonate group. It would be reasonable to assume that a Danish population would be similar to a British one and therefore that it might be safe not to screen these patients for arrhythmias.

Dr Merriman is a GP in Oxford and a member of our regular team of journal reviewers.

The quick study

  • Digitalis users with AF have a greater risk of mortality.
  • Total knee replacements are more likely to be offered to men than to women.
  • Joint line tenderness is a sensitive and specific test for meniscal tears.
  • BP readings are comparable whether taken on bare or covered arms.
  • Bisphosphonates do not increase the risk of AF and atrial flutter according to Danish data.

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