What is the evidence behind treating patients with COVID pneumonia and hypoxia with dexamethasone?
Dexamethasone in Hospitalized Patients with Covid-19 (RECOVERY)
The RECOVERY Collaborative Group. NEJM (February 2021)
Bottom line: This was a controlled, open-label trial comparing the use of dexamethasone to usual care in hospitalized patients with Covid-19. A total of 6425 patients were included in the study, with 2104 in the dexamethasone group and 4321 in the usual care group. The primary outcome was 28-day mortality, and the results showed a lower mortality rate of 22.9% in the dexamethasone group compared to 25.7% in the usual care group (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.001). This difference was more significant in patients receiving invasive mechanical ventilation or oxygen alone, but not in those receiving no respiratory support. In conclusion, the use of dexamethasone in hospitalized Covid-19 patients may lead to lower mortality rates in those receiving respiratory support.
Why do we generally use a threshold of hemoglobin <70 g/L for RBC transfusion in hospital?
A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care (TRICC)
Hérbert P et al. NEJM (February 1999)
Bottom Line: This randomized controlled trial, conducted over a period of 72 hours, compared the effects of a restrictive strategy of red-cell transfusion to a liberal strategy in 838 critically ill patients with euvolemia and hemoglobin concentrations of less than 9.0 g/dL within 72 hours of admission to ICU. 418 patients were randomly assigned to a restrictive strategy of transfusion where red cells were transfused if hemoglobin was less than 7.0 g/dL and hemoglobin concentrations were maintained at 7.0-9.0 g/dL. 420 patients were randomized to a liberal strategy in which transfusions were given when hemoglobin was below 10.0 g/dL and hemoglobin concentrations were maintained at 10.0-12.0 g/dL. The primary outcomes were rates of death at 30 days and severity of organ dysfunction. The results showed no significant difference in 30-day mortality between the two groups (8.7% vs. 23.3%, P= 0.11). The restrictive strategy was found to be more effective in less acutely ill patients and those under 55 years old, but not among patients with clinical significant cardiac disease. The mortality rate during hospitalization was also significantly lower in the restrictive strategy group (22.2% vs. 28.1%, P=0.05). This study suggests that a restrictive strategy may be a better approach for red-cell transfusion in critically ill patients, with the exception of those with acute myocardial infarction and unstable angina.
LINK TO ARTICLE (Hérbert et al.)
How come we don’t do upfront PCI in patients with stable coronary artery disease?
Optimal Medical Therapy with or without PCI for Stable Coronary Disease (COURAGE)
Boden W et al. NEJM (April 2007)
Bottom Line: This randomized trial compared the effectiveness of percutaneous coronary intervention (PCI) with optimal medical therapy to optimal medical therapy alone in reducing the risk of cardiovascular events in patients with stable coronary artery disease. The study included 2287 patients with objective evidence of myocardial ischemia and significant coronary artery disease at 50 U.S. and Canadian centres. Entry criteria included stenosis of at least 70% in at least one proximal epicardial coronary artery and objective evidence of myocardial ischemia (substantial changes in ST-segment depression or T-wave inversion on the resting electrocardiogram or inducible ischemia with either exercise or pharmacologic vasodilator stress) or at least one coronary stenosis of at least 80% and classic angina without provocative testing. 1149 patients were underwent PCI alongside optimal medical therapy, while 1138 patients received medical therapy only. The study found that there was no significant difference in the composite outcome of death from any cause, nonfatal myocardial infarction, and stroke between the PCI group and the medical therapy group over a 2.5 to 7.0 year follow-up period (20.0% vs. 19.5%; hazard ratio, 1.05; 95% CI, 0.87 to 1.27; P=0.62). Therefore, the study concluded that adding PCI to optimal medical therapy did not reduce the risk of major cardiovascular events in this patient population.
LINK TO ARTICLE (Boden et al.)
