Clinical Briefs
By Louis Kuritzky, MD
Clinical Assistant Professor, University of Florida, Gainesville
Dr. Kuritzky is a retained consultant for AbbVie, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Chelsea, Daiichi Sankyo, Forest Pharmaceuticals, Janssen, Lilly, Novo Nordisk, Pfizer, and Sanofi.
PSA Screening: Game Over? Well, Maybe
Barton MK. CA Cancer J Clin 2014;64: 221-222.
In 2008, the United States Preventive Services Task Force (USPSTF) guideline made one of the first steps toward reducing the number of persons screened for prostate cancer by indicating the lack of value for persons ¡Ã 75 years. Four years later, their recommendations were updated into a guideline that advised not performing prostate cancer screening on any men, since benefits could not be confirmed to outweigh risks. So, game over?
A study performed under the leadership of faculty from the University of Chicago department of urologic surgery analyzed data from the National Health Interview Survey, an ongoing interview done annually on 87,500 people in the United States. The subgroup chosen for analysis in this report focuses on men in two age groups: 65-74 years and ¡Ã 75 years. Results of these populations when queried in 2005 and 2010 were compared.
Was the 2008 caveat issued by the USPSTF heeded? For men aged ¡Ã 75 years, investigators found no meaningful difference in the rates of prostate cancer screening comparing results from 2005 interviews (36% screened) and 2010 interviews (34% screened). The majority of these men reported that their physician had advised them to undergo the screening, with only about 25% of men reporting any discussion of potential disadvantages of prostate cancer screening.
Guidelines are only guidelines: That is, it is the artful application of clinical judgment to science that should produce therapeutic wisdom. Nonetheless, clinicians should always carefully examine their process when acting in a way that is directly countercurrent to major national guidelines.
AF is Responsible for Even More Strokes
Gladstone DJ, et al. N Engl J Med 2014; 370:2467-2477.
Atrial fibrillation (AF) is the most potent predictive factor for risk of stroke. The good news is that stroke risk in AF patients can be reduced by more than two-thirds with use of currently available antithrombotic medications, while incurring only a minor risk (< 1.0%/yr) of central nervous system bleed.
I guess the reason we use the words “idiopathic” and “cryptogenic” is because it is difficult for us to say “We just don’t know.” But package the answer in whichever jargon you like, cryptogenic stroke is an important public health issue, since approximately 25% of ischemic strokes are ultimately so-classified.
Before labeling a stroke cryptogenic, an evaluation for underlying pathology is generally performed, which includes scrutiny for AF, since that is so frequently a culprit and so importantly remedied. If AF was not detected in the proximate temporal vicinity of the stroke, can an “innocent” verdict be rendered as far as AF is concerned?
Sometimes, apparently not. Gladstone et al report on the results from cryptogenic stroke/TIA patients (n = 572), half of whom were randomized to 30-day post-event cardiac rhythm monitoring. AF of at least 30 seconds duration was identified in 16.1% of the patients who were monitored.
AF is responsible for a significant number of stroke patients who would not otherwise enjoy the benefits of anticoagulation. More routine inclusion of longer monitoring will help to identify these patients.
Perioperative CV Adverse Events in Stroke Survivors
J©ªrgensen ME, et al. JAMA 2014;312: 269-277.
Once a person has experienced a stroke, risk for future cardiovascular events remains substantially elevated compared to a healthy population.
The perioperative period is known to be a time of increased risk for major adverse cardiovascular events (MACE), and it would be valuable to know the interval after which surgical procedures could be performed with minimum risk of MACE for stroke survivors: Is an operation safe 3 months after a stroke? 6 months? 1 year?
J©ªrgensen et al evaluated data from the Danish Nationwide Cohort Study (n = 481,183 elective noncardiac surgeries in adults) to examine the relative risk for MACE in the general population vs stroke survivors. Even distant from the event, risk for MACE was greater in stroke survivors compared to the healthy population (odds ratio [OR] = 1.46). Additionally, the risk of perioperative MACE was greatest in the time period most proximate to the stroke: OR was as high as 14.2 if surgery occurred within 3 months of stroke, reduced to 4.85 in the 3-6 months post-stroke interval, and reduced further to an OR of 2.47 if surgery was performed at least 12 months post-event. These data should provide impetus to advise stroke survivors that unless there is some urgency to an elective procedure, cardiovascular outcomes are best when elective surgery is performed at least 12 months from the date of the index event.
