Cardiology Update

The current issue of Annals of Internal Medicine published summaries of ten cardiology articles from the past year that the editors selected for their novelty, quality and potential impact on clinical practice. Cardiovascular disease remains the leading cause of death worldwide.

Statins are the most commonly prescribed drugs in the United States and there is consensus that they should be used in patients with multiple risk factors who are at high risk for heart disease. However, there is little data that statins are beneficial in primary prevention. A meta-analysis (data from many trials aggregated and reanalyzed) failed to demonstrate that prescribing statins (such as Lipitor, Zocor, Crestor) to prevent heart disease actually leads to lower mortality in low-risk patients without demonstrated coronary artery disease.

Even in patients with diabetes, a group in which cardiovascular events are common, there are questions about how vigorously physicians should pursue lower lipid levels and lower blood pressure. The new recommendation is that blood pressure goals in the diabetic should be the same as in other patients, since very low blood pressures can have adverse events. Another article refutes the assumption that using additional medication (fibrate plus statin) to achieve a more favorable lipid profile is associated with reduced cardiac events in the diabetic. The best way to reduce risk in the diabetic populations is the same as for all other patients: increased physical activity, increased intake of fruits and vegetables and reduced sodium intake.

Medical imaging has rapidly increased in the past decade and the per capita dose of medical radiation in the United States has increased six-fold from 1980 to 2006. More than 10% of the radiation exposure (excluding radiation therapy) is from myocardial perfusion imaging. In one New York teaching hospital, one-third of the studies were on patients without symptoms. Another article reviewed coronary angiography; here too one-third of the patients were asymptomatic. No research suggests that invasive procedures help patients without symptoms.

The number of procedures that use ionizing radiation (CT, myocardial perfusion imaging, coronary angiography) is increasing and the use of medications to lower lipids and blood pressure is increasing despite little evidence that were are benefiting our patients. We can clearly help our patients by emphasizing life style changes: diet, exercise and smoking cessation.

Ann Intern Med. 2011;154:549-553.