The ORBITA Trial: PCI vs Placebo Procedure for Angina Relief in Stable Angina

29 Oct
October 29, 2018

Background:In the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial [2], there was no difference in MI and death rates between patients with stable coronary artery disease who underwent PCI and controls. In stable angina, the primary goal of percutaneous coronary intervention (PCI) is symptomatic relief of angina, with guidelines recommending its use for those who remain symptomatic despite optimal medical management.  The issue with previous studies is both physicians and patients have not been blinded, therefore the effect size of PCI on symptomatic endpoints can be overestimated due to placebo effect as opposed to true physiological effect.  The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina (ORBITA) trial was designed to assess the effect of PCI versus placebo on exercise time in patients with stable ischemic symptoms in a blinded fashion. Read more →

Performing Procedures Like a Boss, in the ED Without an IV

24 Oct
October 24, 2018

Background: Establishing IV access has become the norm for patients presenting to the ED.  However with increasing patient volumes, difficulty and delays in acquiring IV access, it seems that anything that could expedite care, reduce pain and suffering, and improve patient care would be welcomed in the ED.  There are several tricks I have learned along the way to achieve just this: No IV access, no problem…performing procedures like a boss… Read more →

The Tamiflu Debacle

24 Oct
October 24, 2018

Background:  Oseltamivir (Tamiflu), a neuraminidase inhibitor, was approved by the FDA in 1999.  The majority of the evidence supporting the use of the medication came from trials funded by Roche, the maker of the drug. Safety issues with the drug began sprouting up in 2009, due to case reports in Japan of neuropsychiatric events and these events eventually led to a label warning. The Cochrane collaboration published analyses of the available data in 1999, 2003, and 2006, supporting the use of the drug. However, in 2009, the  Cochrane collaboration began to question Roche about the completeness of the data they were using, which was data from another meta-analysis with 10 RCTs.  Only 2 of those RCTs (Nicholson 2000 and Treanor 2000) were published in peer-reviewed journals.  The other 8 RCTs were presented as proceedings of congress or abstracts in meetings.  Cochrane decided to undertake a complete analysis of full clinical trial data, but had difficulties accessing the data until 2013.  This post will serve as a review of the evidence for and against the use of Oseltamivir (Tamiflu) after the full clinical trial data was finally released. Read more →

The Ottawa SAH Clinical Decision Rule

24 Oct
October 24, 2018

Background: Headache is a common presentation to the emergency department  (ED) accounting for 2% of all visits [1].  Of the patients that present with headache,1 – 3% will be due to a subarachnoid hemorrhage (SAH) [1]. SAH is a true diagnostic dilemma as delays in diagnosis can lead to significant morbidity and mortality. Further complicating matters, almost half of patients will be alert and neurologically intact at first presentation [3].  Non-Contrast Head CT (NCHCT) is very sensitive when performed soon after headache. However, we don’t want to order unnecessary NCHCTs as that increase cost and radiation exposure. Invasive testing such as lumbar puncture, which in itself can be a painful procedure, can also cause headache.  The Ottawa SAH Clinical Decision Rule was designed to help facilitate the identification of SAH in alert, neurologically intact adults presenting to the ED with acute, non-traumatic headache, while minimizing expensive and invasive over testing.  This post will serve as a review of the current literature in the derivation and validation of the Ottawa SAH Clinical Decision Rule. Read more →

SCOT-HEART: CCTA Decreases Long-Term Risk of MI and Death?

22 Oct
October 22, 2018

Background: CT coronary angiography (CTCA) is a relatively new technology that has gained popularity over the past few years in evaluating patients presenting with chest pain. CTCA is an anatomic test that has been shown to increase downstream testing and increase healthcare costs but its impact on patient-oriented benefit has been questioned. Early concerns of CTCA including poor image quality in the obese and high levels of radiation exposure have been mitigated by improved technology.

Another trial, called PROMISE, also evaluated anatomic CCTA vs functional stress testing in greater than 10,000 patients with symptomatic chest pain with suspected CAD.  In this study an initial strategy of CCTA was not associated with better clinical outcomes compared to functional testing over a median follow-up period of two years, and it was also associated with higher radiation exposure and downstream testing.

In this post we will cover the original SCOT-HEART trial published in 2015 [1] and the 5 year follow up of the original SCOT-HEART trial [2]. Read more →