Bruits, vitamins and diabetes

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

Stopping smoking and mortality JAMA 2008; 299: 2,037-47
There is no question that smoking increases the risk of cardiovascular disease (CVD) and respiratory disease. This interesting study looked at the reduction in disease risk in female patients once they have quit. The authors were also interested in whether smoking has a role in the aetiology of ovarian and colorectal cancer.

A total of 104,519 patients were followed between 1980 and 2004 as part of the Nurses' Health Study. A total of 12,483 deaths occurred in the cohort. While 4,485 (35.9 per cent) deaths occurred in the never-smokers group, 7,998 occurred in the current smoker/previous smoker groups.

Smoking-related cancer was 7.25 times more likely among smokers/previous smokers. Colorectal cancer was 1.63 times higher in smokers and 1.23 times higher in previous smokers. The authors didn't find any significant difference in the risk of ovarian cancer between the groups.

All-cause mortality equates to that of a never-smoker 20 years after cessation. The risk of lung disease continued far longer after cessation than for CVD. Age at initiation of smoking influenced mortality figures; those who started early were at greatest risk.

The authors found that 64 per cent of deaths in those who smoked were associated with a smoking-related illness.

Cardiovascular events and B vitamins JAMA 2008; 299: 2,027-36
There is still confusion in the literature as to whether reducing homocysteine levels by dietary supplements reduces cardiovascular burden. Some observational studies, however, have suggested women may benefit from supplementation more than men.

This randomised study looked at whether a folic acid, vitamin B6 and vitamin B12 combination reduces the CVD risk in high-risk women. Nearly 5,500 women with three or more risk factors for CVD were enrolled in the US study. Women were randomised to either drug or placebo and followed up for 7.3 years.

There were no significant differences in cardiovascular events between the two groups despite a significantly reduced homocysteine burden in the intervention arm of the study.

The data provide strong evidence that we should not be routinely advocating the use of these supplements to reduce the risk of cardiovascular disease in our female patients.

Do carotid bruits indicate MI? Lancet 2008; 371: 1,587-94
This study looked at whether carotid bruits were predictors of MI. This may be intuitive given the similarities in pathophysiology and aetiology but do bruits confer a higher risk? This meta-analysis involved 17,295 patients with over 60,000 patient-years of follow up.

In those who had carotid bruits, the rate of MI was 3.69 per 100 patient-years compared with 1.86 in those who did not have bruits. The annual risk of cardiovascular death was more than double in patients with carotid bruits.

We should be aggressive in managing patients with established disease, and even more so with those with carotid bruits.

Metformin versus insulin for gestational diabetes N Eng J Med 2008; 358: 2,003-15
This open study involved 751 women and compared neonatal morbidity in patients who received either metformin or insulin as treatment for gestational diabetes.

Some patients required supplemental insulin in addition to metformin.

Outcome measures included neonatal hypoglycemia, respiratory distress, need for phototherapy, birth trauma, low Apgar score or prematurity. The authors also looked at maternal morbidity.

While adverse outcomes were similar in both groups, 76.6 per cent of women stated they would choose metformin again compared with only 27.2 per cent of women who received insulin. It is clear that metformin is more acceptable to women than parenteral treatments.

Smoking and adolescence Lancet 2008; 371: 1,595-1,602
Intervention and education in the formative years may have a huge impact on the health of our nation. This study involved nearly 11,000 English students aged 12-13.

Half the group was randomised to receive usual smoking education while the other students were exposed to a specialised programme whereby key students would encourage their peers not to smoke.

Overall, students in the intervention group were less likely to smoke than those in the standard education group.

While more data are required to confirm this and develop more effective interventions, it is clear that investment is required in schools to reduce the burden of smoking-related disease in future generations.

Medication compliance Mayo Clin Proc 2008; 83: 529-35
Adherence to prescribed medication plays a major role in the health of patients.

A greater understanding of why patients refrain from taking their medication may improve adherence and the UK disease burden.

This American study identified a number of factors working to reduce the chances of patients taking their medicines. These included transportation and cost.

A fifth of patients did not understand why they were prescribed their medication. Patients felt lower costs, pharmacy counselling and pill boxes would improve adherence.

Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and a member of our team who regularly review journals.

The quick study

  • CVD risk decreases on cessation of smoking but it can take up to 20 years for the risk of lung disease to return to that of a non-smoker.
  • Folic acid and vitamin B combined does not significantly reduce the risk of cardiovascular events in women.
  • Carotid bruits may indicate an increased risk of MI.
  • Metformin, rather than insulin, is preferred by women with gestational diabetes.
  • Smoking education in schools must be improved to reduce the number of smokers in future generations.
  • Pharmacy counselling and pill boxes could improve medication adherence after hospital discharge, along with lower costs and follow-up phone calls.

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