Screening ECG Abnormalities Portend Adverse Cardiac Events in Older Adults.

But cost-benefit analysis is required before routine screening can be recommended.

Traditional risk factors are less accurate for predicting coronary heart disease (CHD) in older adults than in middle-aged adults. Resting electrocardiography (ECG) is not recommended for screening asymptomatic adults, but may be useful in older adults given their higher prevalence of CHD.

A population-based sample of 2200 adults (mean age at entry, 74; 55% women; 59% white) without known CHD was assessed with resting ECG. About 23% had major ECG abnormalities at baseline (e.g., Q-wave abnormalities, left ventricular hypertrophy, atrial fibrillation or flutter, major ST–T wave anomalies). An additional 13% had minor ST–T wave changes. During a median follow-up of 8 years, 351 incident CHD events occurred (96 CHD deaths, 101 acute myocardial infarctions, and 154 hospitalizations for angina or revascularization). In analyses adjusted for traditional cardiac risk factors, risk among participants with minor and major ECG abnormalities compared to those without abnormalities was increased by 35% and 51%, respectively.

Comment: Intriguing as they are, these results do not in themselves support a recommendation for routine electrocardiographic screening in older adults, because we have no data showing that such screening would result in improved clinical outcomes. An editorialist notes that most participants whose risk status was reclassified based on their ECG results were moved into a lower risk category and expects that a cost-benefit analysis would show sufficiently little benefit to justify the cost of widespread screening.

Published in Journal Watch General Medicine



Bevacizumab for Hereditary Hemorrhagic Telangiectasia.

The drug significantly reduced high cardiac output and duration of epistaxis in a small study of patients with HHT.

Hereditary hemorrhagic telangiectasia (HHT) is characterized by repeated episodes of epistaxis; iron-deficiency anemia; telangiectasias; and arteriovenous malformations (AVMs) in the lungs, liver, gastrointestinal tract, and brain. Occasionally, multiple AVMs are located in the liver, resulting in extensive hepatic shunting and high-output cardiac failure. Aside from liver transplantation, few other options are available for patients with this complication. However, there might be a role for agents that target vasculogenesis, such as inhibitors of vascular endothelial growth factor (VEGF).

To assess whether the VEGF inhibitor bevacizumab reduces cardiac output and improves epistaxis duration in this setting, French investigators conducted an industry-supported, prospective, open-label, single-arm study involving 24 evaluable HHT patients with severe hepatic AVMs and high cardiac output. Patients received intravenous bevacizumab (5 mg/kg every 14 days for 2.5 months). Cardiac output, as measured by cardiac index (CI), was assessed by echocardiography at 3 and 6 months.

Results were as follows:

  • CI normalized at 3 months in 3 patients, decreased in 17, and was unchanged in 4.
  • Overall, CI fell at 3 months (mean, 5.01 to 4.20 L/minute/m2; P<0.001) and remained lower at 6 months (4.06 L/minute/m2).
  • Elevated systolic pulmonary hypertension and left ventricular filling pressures were normalized in 5 of 8 and 6 of 14 patients, respectively, at 3 months.
  • The duration of epistaxis decreased by 39% at 3 months (from 221 to 134 minutes per month; P=0.008) and decreased by >30% in 87% of patients.
  • The travel time between the hepatic artery and veins, as measured by contrast-enhanced ultrasound, rose at 3 months (from 2.75 to 3.75 seconds; P=0.03).
  • Liver volume decreased slightly at 3 months, as measured by contrast tomography (1410 to 1242 mL; P=0.08).
  • All quality-of-life measures improved at 3 and 6 months, as indicated by patient responses to the Short Form-36 health questionnaire.
  • Adverse effects included an increase of alanine and aspartate aminotransferase levels in five patients; one patient developed hypertension (grade 3) that responded to treatment with amlodipine.

Comment: Results from this small study suggest that inhibition of VEGF alters blood flow through AVMs, thereby decreasing cardiac output as well as bleeding from distended, fragile intranasal vessels. Physiological improvement persisted for 6 months in some patients. The benefits of bevacizumab need to be confirmed in larger trials, and the safety and effectiveness of other antiangiogenic inhibitors such as thalidomide are being explored (JW Oncol Hematol Jun 15 2010).

Source: Journal Watch Oncology and Hematology


Prostate Cancer: High-Intensity Focal Ultrasound Promising in Small Study .

Focal ablation for prostate cancer could move treatment strategies away from the current whole-gland approach, according to a small study in the Lancet Oncology.

Researchers followed 41 men with localized (unifocal or multifocal) cancers who had received no previous treatment. All underwent MRI to locate the cancers, and all were treated with high-intensity focused ultrasound.

By 12 months, 84% had leak-free and pad-free urinary continence, normal sexual function, and no evidence of clinically significant disease.

Commentators say that with better standardization and patient-selection criteria, focal therapy could become mainstream.

Source:Lancet Oncology