Clinical: Journals Watch - MI, asthma and placebos

Too busy to read the journals? Let Dr Raj Thakkar ease the load.

Sudden death after MI - JAMA 2008; 300: 2,022-9
Coronary artery disease remains the number one killer in the UK. The risk of sudden cardiac death after an acute cardiac event is high.


In the first month after an acute caridac event there is an increased risk of sudden cardiac death

This surveillance study aimed to assess the risk of sudden cardiac death after MI, considering the relationship with recurrent ischaemia and heart failure.

Nearly 3,000 people were included in this US study. Patients who experienced MI between 1979 and 2005 were followed up until February 2008.

Overall, 24 per cent of patients died from sudden cardiac death. The greatest risk for death was in the first month after an event (1.2 per cent). After that, the risk was 1.2 per cent a year, with a five-year cumulative risk for sudden cardiac death of 6.9 per cent.

Risk of death was higher (not statistically significant) between 1979 and 1987 than between 1997 and 2005, presumably reflecting modern medical practice.

After statistical analysis, recurrent ischaemic events were not significantly associated with sudden cardiac death whereas cardiac failure increased the risk of death 4.2-fold (95% CI 3.10-5.69).

It is important to closely monitor our patients discharged after MI, particularly looking for signs of cardiac failure.

Smoking exposure in early-onset asthma - N Engl J Med 2008; 359: 1,985-94
It is known that genetics and parental smoking play a part in asthma risk. Variants at 17q21 have been shown to be associated with asthma.

This interesting genetics-based study looked at 36 single nucleotide polymorphisms (SNPs) in the 17q21 region from over 1,511 patients from 372 families.

The researchers looked at age of onset of asthma and exposure to tobacco smoke in childhood, testing the hypothesis that there may be a genetic predisposition to asthma if exposed to tobacco.

They found 11 SNPs that were significantly associated with asthma (P<0.01). Four of these associations were highly significant (P<0.00001) for early-onset asthma (in patients less than four years of age).

The researchers also found six SNPs that significantly predisposed to early-onset asthma only when exposed to environmental tobacco. This risk was as high as 2.9 times.

This study reiterates how important it is to discuss passive smoking with our young asthmatic patients.

Prescribing placebo treatments - BMJ 2008; 337: a1,938
Psychology plays a huge role in medical practice and prescribing placebos may indeed be beneficial to our chronic disease or 'heartsink' patients.

This US-based cross sectional study surveyed 1,200 physicians (internists and rheumatologists) about their attitude toward placebo drugs.

Overall, 57 per cent of doctors (679) returned the survey and about half of those admitted to prescribing placebo drugs on a regular basis. Sixty-two per cent of responders felt placebos were ethically acceptable.

Placebos prescribed included saline, sugar pills and vitamins. OTC analgesics, antibiotics and sedatives were also used as placebos. These treatments were often promoted to patients as being potentially beneficial.

The debate has now opened as to whether doctors in the UK can ethically and responsibly prescribe placebos with support of our regulatory bodies.

Suicide rates in people of South Asian origin - Br J Psychiatry 2008; 193: 406-9
Suicide is a tragic event and it is imperative that doctors look for the signs and understand the risk factors associated with suicide.

This interesting study looked at suicide among South Asians in England and Wales using a novel piece of software designed to identify South Asian names against the suicide register.

The researchers found the suicide rate for South Asian women over the age of 65 was twice as high as for other women.

It is known that depression among Asian women is prevalent. They also feel reluctant to admit to having depression or to seek medical intervention. The reasons for this are manifold and include social isolation, financial pressure, particularly in older women after the death of their spouse, and stigma.

We as doctors must look for depression and suicide risk in all patients, not least women of South Asian origin.

Homocysteine level and CHD incidence - Mayo Clin Proc 2008; 83: 1,203-12
There is much debate in the literature as to whether raised homocysteine levels confer a higher risk of CHD and whether lowering the levels of homocysteine reduces the cardiovascular burden.

This US meta-analysis aimed to determine whether homocysteine is in fact an independent risk factor for CHD.

Twenty-six articles were found to be of good enough quality to be included in the review. After statistical analysis, the researchers concluded the risk of coronary events was increased by 1.18 (95% CI 1.10-1.26) for every 5 micromol/litre increase in homocysteine.

The relative risk for CHD was found by most studies to be 20-50 per cent for every 5 micromol/litre increase in homocysteine.

Robust data are still required to prove whether lowering levels of homocysteine reduces cardiovascular events and which therapeutic actions are the most effective.

Sure Start local programmes and three-year-olds - Lancet 2008; 372: 1,641-7
The Sure Start scheme was designed to help young children of deprived families, with the aim of promoting good health and development.

This observational study aimed to assess whether the Sure Start scheme does indeed improve the health of three-year-old children and their families.

A total of 5,883 disadvantaged children from Sure Start programme areas were observed and compared to 1,879 deprived children who were enrolled in the Millennium Cohort Study.

Fourteen outcomes were measured including immunisations, language development, father's involvement in care and maternal smoking.

Children in Sure Start areas demonstrated better social development, greater independence, more positive parenting and better home learning environments. While these results are encouraging, it is important to consider how GPs can positively influence deprived families, particularly with respect to immunisation uptake and maternal smoking.

Whether Sure Start benefits children beyond the age of three is yet to be seen.

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

The quick study

  • Post-MI patients are at risk from sudden cardiac death.
  • Early-onset asthma risk is increased by passive smoking and a genetic predisposition.
  • Placebo drugs may be beneficial to patients but doctors are unsure if it is ethical to prescribe them.
  • Suicide rate among South Asian women over age 65 is twice as high as for other women.
  • Homocysteine appears to have an association with CHD but more data are needed.
  • Sure Start programmes improve social development and home learning for young children.

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