Journals watch: CAD, medication errors, preventing asthma deaths

Dr Raj Thakkar summarises the key papers of interest to GPs including HbA1c in non-diabetic patients and coronary artery disease, minimising post-discharge medication errors, effects of taking statins, maternal pertussis vaccination and preventing asthma deaths.

HbA1c levels can predict the risk of CAD in non-diabetic patients (SPL)
HbA1c levels can predict the risk of CAD in non-diabetic patients (SPL)

HbA1c as a predictor of CAD in non-diabetic patients

Mayo Clin Proc 2014 Jul; 89(7): 908-16

This observational study, which included 1,141 patients, aimed to understand the relationship between HbA1c in non-diabetic patients and coronary artery disease (CAD) burden.

Perhaps intuitively, higher HbA1c levels were associated with increases in BMI, BP and glucose.

Unsurprisingly, higher HbA1c levels correlated with CAD burden. After adjusting for confounders, however, HbA1c levels of 5.5-5.7% conferred an OR of 1.8, HbA1c of 5.8-6.1% offered an OR of 3.5, and HbA1c >6.1%, 4.9 times the risk.

Minimising post-discharge medication errors

Mayo Clin Proc 2014 doi: 10.1016/j.mayocp.2014.04.023

Ensuring concordance with medication is always a challenge.

The consequences are far reaching and there is clear evidence that increased concordance reduces unplanned admissions.

Matters become more complicated when medications are changed after a hospital admission, with the additional problems and work generated to reconcile medications after discharge.

Potential correlates, such as numeracy, literacy, marital status and depression, were considered against risk of discordance with post-discharge medication lists.

The discharge lists in this study had an average of 12 reported drugs and the mean patient age was 59 years.

Patients with higher levels of numeracy or literacy were less likely to have difficulties with medication reconciliation.

Possible non-cardiovascular effects of taking statins

BMJ 2014; 349: g3743

This paper details the evidence base behind the possible side-effects of taking statins.

Cancer has largely been discounted. In terms of muscle disorders, statins will increase the risk of myositis in about one in 2,000 patients per year, and rhabdomyolysis in one in 10,000 per year. These effects are seen in higher-intensity regimens.

Myalgia may occur with atorvastatin, but has not been proven with other statins.

The association with diabetes and statins has also been proven, especially in patients already at risk of diabetes. The number needed to harm is 250 and again, the higherintensity regimens are more problematic. Meta-analyses have shown a one in 1,000,000 per year risk of liver failure.

The US Food and Drug Administration has recommended performing baseline liver tests, but states that monitoring is no longer required unless clinically indicated.

While there have been reports that statins increase dementia risk, some trials have shown a reduction in the risk of Alzheimer's disease.

There are risks associated with taking statins, but these drugs also have non-cardiovascular benefits, such as a reduced risk of developing pancreatitis.

Maternal pertussis vaccination

The Lancet 2014; doi:10.1016/S0140-6736(14)60686

The public health campaign in 2012 to vaccinate pregnant women against whooping cough received a varied response.

Proof of effectiveness of such a campaign was lacking at the time. This longitudinal study reviewed cases of pertussis between 2008 and 2013 and should support pro- vaccination arguments.

There was a 68% reduction in cases and a 78% reduction in hospital admissions in 2013 among infants less than three months of age, compared to the same period in 2012.

This was attributable to the vaccine. We should consider the reduction in short-term complications of whooping cough, such as otitis media, subconjunctival haemorrhage and pneumonia.

The role of the GP in preventing asthma deaths

Br J Gen Pract 2014; 64: 329-30

The national review of asthma deaths highlights what is often not high on the agenda.

The consequences of ignoring the report may be devastating and furthermore, an asthma death is usually in a young person and the majority of these are preventable.

Some of the underlying themes from the report were failure to perform asthma reviews and to follow up patients after an episode.

This review summarised key messages to help reduce the risk of death in asthma, including improving accuracy of diagnosis and considering asthma as a chronic disease.

We need to be reaching out to schools and to patients who do not come for review, educating them and ensuring they understand their disease and how to manage it.

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

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

  • Produce a patient leaflet or poster about statins, in order to alleviate patients' fears.
  • Lobby your CCG to provide a mechanism to improve the way hospitals educate patients on their discharge summaries.
  • Discuss the findings of the asthma inquiry with your practice staff and CCG, and make a plan to reduce the risk of unplanned hospital admissions.

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