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Monthly Archives: May 2012

This post refers to

‘2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker : The ADAPT Trial’  by Martin Than, Louise Cullen, Sally Aldous, William Parsonage and others published online in The Journal of the American College of Cardiology http://dx.doi.org/10.1016/j.jacc.2012.02.035

Last year I wrote under this title about the growing body of work accumulating around more rapid and safe approaches to the assessment of patients presenting with acute chest pain.

Here is a paper that takes this further and is based on a large study of an Australasian cohort of patients with undifferentiated chest pain presenting to emergency. The study refines the groups previous work published in The Lancet last year. The main refinement has been to reconfigure the accelerated diagnostic protocol (ADP) to use cardiac troponin as the only biomarker as opposed to the multi marker approach used in the earlier ASPECT study. This eliminates some of the ‘noise’ introduced by the additional biomarkers and therefore grows the size of the group that can rapidly be shown to be at low risk of a short term adverse cardiac outcome to about 20% of all comers whilst still maintaining an extremely high level of safety (a negative predictive value of >99%).

Of considerable importance is the fact that this was all achieved with testing at only 2 hours after presentation using contemporary sensitive (but not highly sensitive) troponin assays.

It’s clear that while many labs have already switched to new highly sensitive troponin assays there is still a lot to be learnt about how even the contemporary assays can be best utilised. It’s even more clear that the prevailing diagnostic paradigms for chest pain that advocate 6-8 hours of observation and testing with contemporary assays or unvalidated approaches to small changes in high sensitivity troponin assays are already in need of updating.

For additional commentary see theheart.org here

This post refers to

‘Association of Coffee Drinking with Total and Cause-Specific Mortality’ by Neal Freedman, Y Park, CC Abnet and others published in the New England Journal of Medicine May 17th 2012; 366:1891-1904 http://www.nejm.org/doi/full/10.1056/NEJMoa1112010

You wouldn’t know about the turmoil at The Cardiologists house over the last two months as the kitchen renovations lurched from one catastrophe to another but one of the best things to come out of all of this is that we were given an espresso machine. I’ve always gazed at these things with some desire but also a deal of scepticism about whether I’d actually use the damn thing when a 10 second cup of instant was there begging… and also of course the concern regarding the possibility of discovering that delivering a flat white was more technically challenging than performing a coronary angiogram in an 82 year old smoker with tortuous iliacs…

So I’ve surprised myself that I have become the house barista and that the noise of the pressure pump and the hiss of steam has come to accompany all of our coffees but not nearly as surprised as when I read the results of this study published on line in last weeks New England Journal of Medicine.

I’ve always enjoyed my coffee with something of a guilty pleasure underpinned by an almost certain belief that it can’t be good for me…but it looks like I’ve been wrong and that now I can watch that espresso drip with the knowledge that it not only tastes good but might actually be doing me good.

There is always some hazard in the interpretation of this kind of observational study and it certainly does nothing to prove causality but it’s a huge and powerful study (5 million plus patient years of observation and 50 thousand plus end points) with few other limitations which seems compelling. In a nut shell the study shows a considerable reduction in the risk of all cause mortality in men and women who drink coffee compared to those who don’t. Moreover, there seems to be something of a dose response (advise caution here) and no loss of effect for those who drink decaff. The last point is interesting in that it suggests that even if caffeine has a detrimental effect than it is probably offset by a beneficial effect of other substances in the coffee, for example anti-oxidants.

I need a coffee.