Rhythm and reviews
Back in those dark early days of my medical career it seemed that inpatients developed atrial fibrillation on a daily basis, and much time was spent stressing about zigzagging INRs. When a patient’s underlying illness improved, often the atrial fibrillation resolved, but patients were still discharged with their yellow books and the promise of a call from the anticoagulation clinic. But does transient atrial fibrillation during a hospital admission need the same management as paroxysmal atrial fibrillation, with lifelong anticoagulation?
A new cohort study matched people admitted to hospital for non-cardiac surgery or medical illness who had transient new-onset atrial fibrillation with inpatients of the same age and sex on the same ward who didn’t develop atrial fibrillation during their admission. Each had a 14 day electrocardiogram (ECG) at one and six months, and a 12 lead ECG after 12 months. The recurrence rate for the 139 people who had transient atrial fibrillation in hospital was much higher—33% at 12 months compared with just 5% among the controls—suggesting long term anticoagulation is appropriate.
Ann Intern Med doi:10.7326/M23-1411
Presentation tips
Hold the front page of your slide-deck on modifiable risk factors and cardiovascular disease: over half of cases of cardiovascular disease and one in five deaths may be attributable to five modifiable risk factors. This statistic is sure to grab any audience’s attention and is the perfect base for some interaction (“Can anyone guess what the five risk factors are?”) and the chance to have some stock photos spinning onto the screen with each press of your laser clicker: high body mass index, high systolic blood pressure, high non-HDL cholesterol, current smoking, and diabetes. Next, pause and say slowly, “I think that’s worth repeating: one…in…five…deaths,” and wait for the heckle: “According to who?” then try not to sound too smug as you reply “According to a pooled analysis of individual level data from over 1.5 million people across 112 cohort studies across 34 countries published in NEJM.” Drop the mic (or pointer) and walk off stage to rapturous applause.
N Engl J Med doi:10.1056/NEJMoa2206916
Big news for large clots
Until now, evidence on endovascular thrombectomy in people with acute ischaemic stroke due to large vessel occlusion has pointed towards benefit mostly in those with minimal or moderate infarct size. Whether it helps improve long term outcomes in those with large infarcts has been unclear, partly due to trials selecting patients using advanced imaging techniques that aren’t usually available in practice. Now the TENSION study has, for the first time, found that simple non-contrast computed tomography or magnetic resonance imaging can be used. Participants with acute ischaemic stroke with a large infarct due to large vessel occlusion in the anterior circulation received either endovascular thrombectomy or medical treatment. The study’s findings are likely to have a major impact after it found that endovascular thrombectomy led to important improvements in functional outcome and reduced mortality at 90 days, with no safety concerns.
Lancet doi:10.1016/S0140-6736(23)02032-9
Mixed results for taper treatment
More than half of people with polymyalgia rheumatica get stuck on a low dose of prednisolone as they try to taper off treatment, putting them at risk of the many and various harms of long term corticosteroids. Interleukin 6 is thought to play a role in the pathogenesis of polymyalgia rheumatica, leading to interest in sarilumab, a monoclonal antibody that blocks the interleukin 6 pathway, as a potential treatment. A phase 3 randomised control trial of sarilumab with a 14 week prednisolone taper versus placebo and a 52 week prednisolone taper found that 28% of those in the sarilumab group achieved sustained remission after a year compared with 10% of the placebo group. However, only 78 of the 118 people in the study completed treatment, and safety data were limited because of the study being halted by the pharmaceutical company sponsor well before the target number of 280 people had been enrolled.
N Engl J Med doi:10.1056/NEJMoa2303452
Get ready for tirzepatide
Tirzepatide is coming! Draft NICE guidance due to be fully published this month recommends tirzepatide, given as a once weekly injection, as an option for people with type 2 diabetes when triple therapy has been ineffective and the person either has a body mass index >35 or weight loss would benefit other comorbidities, or when insulin would have significant occupational implications. Another randomised control trial has reported favourable outcomes with tirzepatide in people with type 2 diabetes—this time compared with prandial fast acting insulin (insulin lispro) when added to basal insulin. It found that, in the 1428 people recruited from 15 countries, people taking weekly tirzepatide had a mean change in baseline HbA1c of −2.1% after a year, compared with a change of −1.1% in those allocated to prandial insulin lispro.
JAMA doi:10.1001/jama.2023.20294
