Journals watch - Stroke, statins and mental health

Too busy to read the medical journals? Let Dr Raj Thakkar be your guide to the latest findings.

NATIONAL GUIDELINES ON BP LOWERING IN STROKE - BMJ 2006;332:617-8

Target BP for post-stroke patients in the UK varies. The British Hypertension Society recommends a BP target of 130/80mmHg in post-stroke patients; others are not so aggressive. Guidelines are largely based on perindopril protection against recurrent stroke study (PROGRESS) data. This Birmingham-based study aimed to compare the PROGRESS trial population with the post-CVA (and TIA) population in primary care.

Patients in primary care were on average 12 years older and twice as likely to be women than those studied in PROGRESS. PROGRESS patients were studied approximately eight months after their event compared with 2.5 years in this study group. PROGRESS participants had a higher BP and they were less likely to have been receiving antihypertensive medication.

This study has brought into question how applicable PROGRESS data are when we are treating stroke patients in the community.

MAINTENANCE OF MAJOR DEPRESSION IN OLD AGE - N Engl J Med 2006;354:1,130-8

Depression in the elderly can lead to significant morbidity and mortality and has a high risk of recurrence. This double-blinded US study assessed the use of paroxetine and psychotherapy as maintenance treatments in over-70s with a diagnosis of major depression.

Just over half of the patients studied were experiencing their first episode of depression. The acute episode was treated with paroxetine and psychotherapy. Maintenance therapy was then studied over a two-year period or until depression recurred, with a view to assess the best regimen to prevent relapse.

Depression recurred in 35 per cent of patients receiving both paroxetine and psychotherapy, 37 per cent of those receiving the antidepressant and clinical management sessions, 58 per cent with placebo and clinical management sessions, and 68 per cent of those having psychotherapy and placebo.

Maintenance therapy with paroxetine significantly reduced the chance of relapse in major depression affecting the elderly, whereas psychotherapy has limited value.

PATIENT DEMAND INCREASES PRESCRIBING FIVE TIMES - Br J Gen Pract 2006;524:183-90

This interesting Belgian-based prospective study aimed to estimate the influence of patient demand on prescribing rates for cough. Seventy-two GPs and 1,448 patients were involved.

Of the patients, 500 received antibiotics, 218 of whom had expressed a wish for antibiotics. Doctor-perceived patient demand for antibiotics increased prescribing by nearly five times.

Is giving patients what they want good doctoring or reinforcing their behaviour? The jury is still out on the issue in the UK.

STATIN AND CORONARY ATHEROSCLEROSIS REGRESSION - JAMA 2006;295:E1-E10

Previous studies on the effects of statins on atheroma load have shown a slowing of disease progression. This study used intravascular ultrasound to assess whether high statin doses could reverse intracoronary atheroma.

Rosuvastatin 40mg per day was administered to 507 patients in this multinational blinded study. After two years, 349 patients remained in the study. A 53.2 per cent reduction in LDL and a 14.7 per cent increase in HDL was demonstrated. An overall reduction in atheroma load was shown by serial intravascular ultrasound. Further work is needed to determine the effect on clinical outcome. Should we be more aggressive when prescribing statins in high-risk patients? We shall see.

INFORMING PATIENTS

Lowering BP in stroke guidance is not always applicable in the community.

Elderly patients with depression can have their risk of relapse reduced by maintenance therapy using paroxetine.

Patient demand for antibiotics increased prescribing by nearly five times.

High-dose statins prevent intracoronary atheroma.

RESEARCH OF THE WEEK - Coagulation in flight Lancet 2006;367:832-8

It is well-known that flying is a risk factor for DVT, but the underlying mechanisms remain unclear. The authors investigated whether flying is associated with a hypercoaguable state.

Seventy-one people took part in this cross-over study; 11 participants had factor V Leiden and 15 were using the oral contraceptive pill. An eight-hour flight was tested against two controls - eight hours either of watching movies or of daily life.

Markers of coagulation were measured in all three groups. The study demonstrated a marked increase in thrombin-antithrombin complex in the flight group compared to a fall in coagulation markers in the controls. Participants with the factor V Leiden mutation who were taking the Pill had the greatest increase in coagulation. Perhaps airlines should issue health warnings with tickets or screen high-risk groups and issue heparins.

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