Journals Watch - Heart failure and diarrhoea

Not had time to read the journals? Let Dr Raj Thakkar bring you up to date with the latest research.

 Type 2 diabetes is an important risk factor for heart failure (Photograph: SPL)
Type 2 diabetes is an important risk factor for heart failure (Photograph: SPL)

Left ventricular diastolic dysfunction and heart failure
JAMA 2011; 306: 856-63

Left ventricular diastolic dysfunction has firmly embedded itself as a clinical entity at primary care level but data supporting any particular treatment are lacking. One question that eludes both patients and doctors is the prognosis.

This prospective cohort study included 2,042 participants, aged 45 years or above, who were reviewed at two points over a four-year period. The prevalence of diastolic heart failure increased from 23.8% to 39.2% among the cohort. In addition, diastolic function worsened in 23.4% of the study population and an improvement was demonstrated in only 8.8%, the rest remaining static. Being aged 65 years or older was considered a risk factor for disease progression and increased the risk of developing cardiac failure.

There is a lot to learn about diastolic disease. However, this study helps us at least to inform our patients a little better.

Cholesterol-lowering foods and serum lipids
JAMA 2011; 306: 831-9

Recent data have shown that the longer people remain obese, the greater their mortality risk. This Canadian study compared a standard low-fat diet with two dietary portfolios of increasing intensity (consisting of foods with recognised cholesterol-lowering properties), comparing LDL between the three groups over a six-month period.

Subjects in the intensive diet group experienced a 13.8% reduction in LDL compared with a 3% reduction in the control group. While both groups achieved a favourable improvement in lipid profile, the intense diet attained a greater outcome.

It would be helpful to understand whether the diet used translated to real clinical endpoints. Nevertheless, if patients are followed up regularly and motivation to continue intensive diets is achieved, the health benefits could be huge.

Diarrhoea-associated haemolytic uraemic syndrome
Lancet 2011: doi:10.1016/S0140-6736(11)61145

As seen in the recent outbreak in Germany, haemolytic uraemic syndrome (HUS) is a potentially life-threatening disease that is often caused by toxin producing Escherichia coli. The bloody diarrhoea, haemolysis, thrombocytopenia and renal failure pose a significant threat to life.

Antibiotics have not been shown to be of benefit in HUS and treatment is supportive. This five-patient Danish study considered the effectiveness of plasma exchange as a therapeutic modality in HUS caused by Shiga-toxin-producing E coli serotype O104:H4.

Outcome measures included recovery of platelet count and eGFR, and a normalising lactate dehydrogenase (LDH). Interestingly, the researchers found that the sooner plasma exchange was initiated; the quicker the LDH fell to normal levels. All five patients recovered and were discharged seven days after treatment commenced.

While more rigorous trial data are needed, plasma exchange offers hope for this potentially fatal disease.

Assessment of primary headache subtypes
BMJ 2011; 343:d5076

Most doctors fear missing a diagnosis of subarachnoid haemorrhage, temporal arteritis or tumour when faced with a patient with headache, although we know stress, eye-strain and migraine are more common.

This prospective follow-up study in Switzerland involved nearly 600 people, reviewing them seven times over a 30-year period. The one-year prevalence of migraine with aura was 0.9%, affecting women 2.8 times more than men whilst migraine without aura had a one-year prevelance of 10.9%, affecting just more than twice as many women as men.

The average one-year prevalence for tension headache was 11.5%. The 30-year cumulative data for migraine without aura was 36% and 29.3% for tension headaches.

Given that the lifetime risks of malignant brain tumour subarachnoid haemorrhage are both around 0.007%, these data should help us reassure our patients.

Apixaban versus warfarin in AF
N Engl J Med 2011: doi 10.1056/NEJMoa1107039

Factor Xa inhibitors are now coming into the clinical arena, but how do they fare against warfarin? This double blind study compared apixaban, 5mg twice daily with warfarin in more than 18,000 patients with AF and at least one other risk factor for stroke. Patients were followed up for 1.8 years.

The annual combined rate of ischaemic stroke, haemorrhagic stroke or embolic disease was 1.27% in the apixaban group and 1.6% in the warfarin group.

In addition, the haemorrhagic stroke rate was 0.24% a year in the apixaban group and 0.47% a year in patients taking warfarin.

This sponsored study was designed to demonstrate that apixaban was not inferior to warfarin; however, it proved to be superior in both its efficacy and safety profile in AF.

Outdoor sports and incidence of skin lesions
Br J Dermatol 2011; 165: 360-7

Research has revealed that children who participate in outdoor sports are at increased risk of developing UV radiation-induced skin lesions. The authors investigated the relationship between outdoor sports and the development of melanocytic naevus in 660 11-year-olds and evaluated the UV-protective measures used by soccer players and the public at a one-day soccer tournament.

Children who played outdoor sports had higher naevus counts and acquired naevus counts. The children and parents at the one-day soccer tournament were inadequately protected against the sun.

The authors conclude that sun protection campaigns should target children who do outdoor sports.

  • Dr Thakkar is a GP in Buckinghamshire and a member of our team who regularly review the journals

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Review all of your patients in AF, ensuring they have an annual CHA2DS2-VASc score and anti-coagulate them accordingly.
  • Hold a clinical meeting discussing HUS, its causes, presentation and what actions your practice should take when a patient has HUS.
  • Invite your patients, including your patient participation group, to a road show to discuss common clinical presentations, including headache.

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