Clinical Briefs
Clinical Briefs
Meta-Analysis of Trials for Stable Angina
Despite many years of use of the three traditional classes of anti-anginal medications, none has emerged as distinctly superior. Because of demonstrated reductions in post-MI mortality with beta-blockers, consensus has generally suggested them as first-line therapy. Since some patients, especially those with bronchospastic lung disease, tolerate calcium channel blockade better than beta blockade, this class of agents also sometimes holds first-choice status. This study analyzed by meta-analysis all randomized trials (1966-1997) of at least one week duration, which compared at least two of the three different drug classes.
Most of the analyzed studies were beta blocker vs. calcium antagonists. Comparing outcomes of cardiac death, MI, angina episodes, use of nitroglycerin, and exercise time, neither class of drug emerged significantly superior. The only statistically significant difference between the classes was in respect to withdrawal for adverse events, for which beta blockers fared more favorably than calcium antagonists.
Studies comparing nitrates with calcium antagonists did not show any significant between-class differences; similarly, although comparisons between beta-blockers and nitrates were the least frequent, no clear advantage of either class emerged.
Since all three classes are equally efficacious, the fact that beta-blockers enjoyed more favorable withdrawal rates suggests that they remain first- choice therapy.
Heidenreich PA, et al. JAMA 1999; 281:1927-1936.
Effect of Cigar Smoking on the Risk of Cardiovascular Disease, COPD, and Cancer in Men
The general public does not have the same perceptions about cigar smoking as cigarette smoking in reference to adversities such as COPD and cancer. Between 1993 and 1997, cigar sales increased almost 50%, predominantly due to use by young and middle-aged men. The current study examined the relationship between cigar smoking and cardiovascular disease among persons with no history of current or past cigarette smoking or current pipe smoking.
The population studied included 17,774 men, of whom 1546 were cigar smokers. The entire cohort was followed from 1971-1995. Cigar smokers were at increased relative risk for coronary heart disease and COPD. Cancers of the digestive tract and lung were twice as frequent among cigar smokers. There appears to be a dose-response relationship.
Consumption of large amounts of alcohol had a synergistic effect for relative risk of digestive and oropharyngeal cancer.
Other studies have implicated cigar smoking in a negative light, both in persons with and without pre-existing cardiovascular disease. This study, as well as others, has failed to demonstrate a relationship between cigar smoking and cerebrovascular disease. Iribarren and associates conclude that cigar smoking causes substantial increases in COPD and cancer, despite the recent surge in the popularity of this habit.
Iribarren C, et al. N Engl J Med 1999; 340:1773-1780.
Ultrasound Therapy for Calcific Tendinitis of the Shoulder
Although not always symptomatic, calcification of the supraspinatus tendon of the shoulder is characterized by shoulder pain, often with associated rotator cuff dysfunction and limitation of motion. Surgical treatments usually alleviate pain and restore function, but patients will generally opt initially for noninvasive treatments, such as ultrasound.
Small, earlier trials of ultrasound have suggested that such treatment may cause shoulder calcifications to disappear. The purpose of this trial was to assess pulsed ultrasound in a large controlled trial for idiopathic calcific tendinitis.
Sixty-three patients were enrolled over 30 months, each demonstrating discrete radiographic evidence of calcific tendinitis, coupled with shoulder pain or restricted range of motion. Ultrasound treatment (and sham ultrasound = same device, same methodology, but generator turned off) was administered daily on weekdays for 15 minutes for three weeks, then thrice weekly for three weeks. At this level of intensity, sham ultrasound is not distinguishable from active by subjects. Radiographs were obtained at baseline, six weeks, and nine months.
Ultrasound treatment produced calcium deposit resolution in 19% of patients, and reduced calcification by half in 28% (vs 0% and 10% for placebo, respectively). At the post-treatment nine-month radiography, 65% of ultrasound recipients had resolved or reduced calcification, as compared with 20% of placebo recipients.
Ebenbichler and colleagues conclude that ultrasound is beneficial in resolving calcifications of shoulder tendinitis.
Ebenbichler GR, et al. N Engl J Med 1999;340:1533-1538.
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