In patients with cancer, how does LMWH compare to warfarin for preventing recurrent VTE?
Low-Molecular-Weight Heparin versus a Coumarin for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer (CLOT)
Lee A et al. NEJM (July 2003)
Bottom line: This randomized controlled trial compared the efficacy of low-molecular-weight heparin (dalteparin) with an oral anticoagulant in preventing recurrent thrombosis in patients with cancer. The study included 672 patients with acute, symptomatic proximal deep-vein thrombosis, pulmonary embolism, or both. The intervention group received dalteparin (200 IU/kg subcutaneously) once daily for five to seven days and a coumarin derivative (e.g. warfarin) for six months (target INR 2.5), while the comparator group received dalteparin alone for six months (200 IU/kg once daily for one month, followed by a daily dose of approximately 150 IU/kg once daily for five months). The primary outcome of recurrent venous thromboembolism at six months was significantly lower in the intervention group compared to the comparator group (9% and 17%, respectively; hazard ratio, 0.48; P=0.002). There was no significant difference in major bleeding or any bleeding between the two groups. The mortality rate at six months was 39% in the dalteparin group and 41% in the oral-anticoagulant group. The study concluded that dalteparin was more effective in preventing recurrent thromboembolism without increasing bleeding risk in patients with cancer.
In Black patients with HFrEF, what’s the rationale for adding on hydralazine and isosorbide dinitrate to their treatment regimen?
Combination of Isosorbide Dinitrate and Hydralazine in Blacks with Heart Failure (AHeFT)
Taylor A et al. NEJM (November 2004)
Bottom Line: This randomized controlled trial examined the efficacy of adding isosorbide dinitrate (ISDN) and hydralazine to standard therapy in Black patients with advanced heart failure. 1050 Black patients with NYHA class III or IV heart failure with dilated ventricles were randomly assigned to receive a fixed dose of ISDN plus hydralazine or placebo in addition to standard therapy for heart failure. The primary outcome, a composite score of death from any cause, first hospitalization for heart failure, and change in quality of life, was significantly better in the intervention group (–0.1±1.9 vs. –0.5±2.0, P=0.01; range of possible values, –6 to +2), as were its individual components. There was a 43% reduction in the rate of death from any cause (hazard ratio, 0.57; P=0.01), 33 percent relative reduction in the rate of first hospitalization for heart failure (16.4 percent vs. 22.4 percent, P=0.001), and and an improvement in the quality of life (change in score, –5.6±20.6 vs. –2.7±21.2, with lower scores indicating better quality of life; P=0.02; range of possible values, 0 to 105). The study was terminated early due to a significantly higher mortality rate in the placebo group. The addition of isosorbide dinitrate plus hydralazine was found to increase survival in this patient population.
Why should early surgery be considered in patients with infective endocarditis?
Early Surgery versus Conventional Treatment for Infective Endocarditis (EASE)
Kang DH et al. NEJM (June 2012)
Bottom Line: This randomized trial compared early valve surgery (replacement or repair) within 48 hours to conventional treatment in 76 patients with left-sided infective endocarditis, severe valve disease, and large vegetations. The primary outcome was a composite of in-hospital death and embolic events within 6 weeks. The intervention group had a significantly lower rate of the primary outcome compared to the comparator group (3% and 9%, respectively; hazard ratio, 0.10; 95% confidence interval [CI], 0.01 to 0.82; P=0.03). There was no significant difference in all-cause mortality at 6 months between the two groups (3% and 5%, respectively; hazard ratio, 0.51; 95% CI, 0.05 to 5.66; P=0.59). The rate of the composite end point of death from any cause, embolic events, or recurrence of infective endocarditis at 6 months was also significantly lower in the intervention group (3% compared to 28% in the conventional treatment group; hazard ratio, 0.08; 95% CI, 0.01 to 0.65; P=0.02). Overall, early surgery effectively decreased the risk of systemic embolism in this patient population, thus significantly reducing the composite end point of death from any cause and embolic events.
