Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is an advisor for Endo, Kowa, Pricara, and Takeda.
Beta-Blocker Use in Situations Other than Just Post-MI
Source: Bangalore S, et al. JAMA 2012; 308:1340-1349.
Current standard-of-care management of post-myocardial infarction (MI) patients includes long-term use of a beta-blocker, unless otherwise contraindicated. The length of the leash on this concept is not long, however, as prospective data confirming benefits of beta-blockers post-MI are limited to just a few years. Since clinicians have not been given concrete advice about when to stop beta-blockers, most patients are kept on beta-blockers indefinitely. Perhaps our indecisiveness is bolstered by anxieties related to the potential consequences of beta-blocker withdrawal in persons with known coronary artery disease (CAD).
In the absence of data from a randomized, prospective, long-term trial, observational data may provide some clues about the relative benefit (or lack thereof) of beta-blockers in at-risk populations. To that end, Bangalore et al report on the outcomes of three different at-risk populations from a CAD registry: post-MI patients (n = 14,043), CAD patients without history of MI (n = 12,012), and patients with CAD risk factors but no known CAD (n = 18,653). Study subjects were enrolled in 2003-2004, and followed for approximately 4 years.
Beta-blocker use was not associated with improved outcomes in any of the three subgroups, even the one group we take for granted that there will be beneficial effects: the post-MI group. In the 1990s, the term "cardioprotective" was sometimes used in reference to beta-blockers. Although this may be true for the few short years immediately after an MI where older clinical trials have found a benefit, whether such benefits persist, or extend to other at-risk groups, remains to be determined.
Long-Term Sexual and Psychological Adverse Effects of Finasteride
Source: Irwig MS. J Clin Psychiatry 2012;73:1220-1223.
Cutaneous dihydrotestosterone is etiologically involved in the development of male pattern baldness. Since finasteride blocks the conversion from testosterone to dihydrotestosterone, it is commonly used to treat the disorder. Systemic alpha-reductase inhibitors like finasteride are occasionally associated with sexual side effects, but only recently has there been the suggestion that finasteride-associated sexual side effects might persist beyond the time treatment is administered. Additionally, recent FDA labeling changes have added depression as a recognized adverse effect of finasteride treatment. Although mechanisms to explain persistent adverse sexual effects are unclear, some animal data suggest persistent diminution in penile relaxation and contraction subsequent to finasteride.
From a population of young men (mean age 31 years) with male pattern baldness (n = 91), Irwig compared men who reported sexual dysfunction for at least 3 months after finasteride cessation to men with male pattern baldness who had not used finasteride. Outcomes of interest were depression scores and suicidal thoughts.
Depression, depressive symptoms, and suicidal thoughts were all substantially more common in the former finasteride users than controls. For example, 75% of former users had a Beck Depression Inventory Score of at least 14 (confirming depression) as opposed to 10% of controls. It is important that clinicians recognize the potential for enduring adverse sexual and psychological symptoms associated with finasteride.
Novel CV Risk Markers: How Much Cluck for the Buck?
Source: The Emerging Risk Factors Collaboration. N Engl J Med 2012;367:14: 1310-1320.
The c-reactive protein (crp) debate has no end in sight. While traditional risk stratification tools like the Framingham Risk Score remain well established to distinguish high- and low-risk groups, the intermediate-risk group is the population in which further refinement in risk score might be helpful. Tools like CRP and fibrinogen, when applied to persons of intermediate Framingham risk, might help identify a subgroup that merits consideration for interventions like statins.
The Emerging Risk Factors Collaboration analyzed data from prospective cohort studies (n = 246,669) that included persons free of CV disease at baseline in whom CRP, fibrinogen, and components of Framingham risk score were available. Among persons with an intermediate Framingham risk score (10-20% risk of CV event over the next 10 years), the addition of either CRP or fibrinogen to risk assessment would result in reclassification of approximately 5% from intermediate to high risk. Such risk status elevation would justify statin treatment. According to current outcomes data, statin intervention in this population would prevent one CV event for every 440 intermediate-risk persons screened. Results were similar for fibrinogen.
The results obtained are "modeled" results rather than actual outcomes. CRP and fibrinogen testing are readily available. Yet, the number needed to test for avoidance of one CV event more than 400 is substantial. The authors do not offer an opinion on the propriety of such an investigation as CRP or fibrinogen; rather, they simply provide a metric to help quantify how much cluck for the buck one might anticipate.
Beta-Blocker Use in Situations Other than Just Post-MI; Long-Term Sexual and Psychological Adverse Effects of Finasteride; Novel CV Risk Markers: How Much Cluck for the Buck?You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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