BMJ 2010: 341: 513 – 62 (11th September)

An important point from the first editorial – Stop dishing out medication on the basis of surrogate endpoints hyped up by pharmaceutical companies.  Or, at any rate, think twice and three times about it.  Surrogate endpoints, no matter how promising-looking, are not the same as actual evidence of favourable risk:benefit ratios, and let’s all keep that in mind.  The drug in question here, by the way, was rosiglitazone, but how many others could just as well have been the subject?  In view of this, it seems timely that another editorial reminds us of the possible risks of bisphosphonates – one case report of a fatal perforated oesophagus and one of an oesophageal stricture resistant to dilatation (the latter in a woman who had only been on alendronate for ten months and had, apparently, taken it correctly in that time).  Granted, the occasional scare story isn’t any better than surrogate endpoints at letting us make a proper weighing-up of risks and benefits, but… it’s still a salutary reminder to be a bit more careful with the prescriptions for prophylactics.  (And this was then followed up with a cohort study later in the journal, showing bisphosphonate prescription for >10 months to be associated with an increased risk of oesophageal cancer (though not stomach or colorectal cancer).  Since the relative risk was 2.24 this must work out to a fairly small absolute risk, but, still… worthy of consideration.)

Are people who’ve inherited the fat gene doomed to a life of obesity?  Not necessarily – exercise still reduces the probability of them becoming overweight, according to studies in PLoS Med, whatever that is.

General increases in fruit and vegetable consumption don’t seem to reduce risk of Type 2 diabetes, according to a study published here.  However, green leafy vegetables do seem to have an effect, so patients at risk of diabetes should do what Mother always told them and eat their greens.

In last week’s BMJ review, I mentioned that gestational hypertension was linked to an increased risk of hypertension later in life.  However, is this cause and effect or is it just that the risk factors for hypertension will increase your risk both of gestational hypertension and of later-life hypertension?  Probably the latter, according to a study in Circulation reported in Minerva.

Now, the review article – NICE guidelines on transient loss of consciousness.  For starters, all LOCs are cardiac until proven otherwise, it seems.  Anyone with transient LOC who isn’t diagnosed with syncope, epilepsy, or postural hypotension should be referred to cardiology, and everyone with transient LOC should have an ECG with either automated interpretation or interpretation by someone competent in identifying the listed abnormalities.  I’d be interested to know whether this is actually a useful screening test in, say, a teenage girl with a textbook history of vasovagal faint, but the guidelines do specify everyone so there you go.

Some cardiology referrals, of course, are more urgent than others.  The red flags requiring the cardiology referral to be within 24 hours are:

  • Loss of consciousness occurring during exertion
  • New/unexplained SOB
  • CCF
  • FH of sudden cardiac death in <40s
  • Heart murmur
  • Red flag abnormalities on the ECG

So what are those red flags to look for on the ECG?  Well, I think I’d have known to refer patients with sustained atrial arrhythmias, inappropriate persistent bradycardia, or pathological Q waves.  However, here are some things I wouldn’t have realised count as red flags in patients with transient LOC:

  • Any conduction abnormality – LBBB, RBBB, or any degree of heart block.
  • LVH or RV
  • Long or short QT interval (normal is 350 – 450 ‘corrected’, whatever ‘corrected’ means)
  • Any ventricular extrasystoles
  • Any ST or T-wave abnormalities
  • Paced rhythm
  • Brugada syndrome, whatever the hell that is
  • Ventricular pre-excitation, ditto (I see why it’s advised that these ECGs be reviewed by either an automated system or an expert).

What other signs should we look out for particularly?  Well, the other big thing to look for, of course, is epilepsy.  Reasons to suspect epilepsy include:

  • A bitten tongue
  • Head turning, unusual posturing, or prolonged limb jerking during the LOC
  • Witnessed but unremembered abnormal behaviour before/during/after the LOC
  • Confusion afterwards
  • A deja vu or jamais vu prodrome (jamais vu is the feeling that something is happening for the first time despite rational knowledge that it isn’t).

If any of these are present, refer for assessment by epileptic specialist within two weeks (lots of luck with that, but a doctor can try, I suppose). 

However, the final message from this seems to be that it is perfectly OK to diagnose syncope if you feel that’s the way the history’s pointing and if examination and ECG don’t throw up any red flags to the contrary.  The article stated that healthcare professionals often seem to lack the confidence to diagnose simple faints.  Not surprising with all those red flags to worry about, but let’s not let ourselves get so worried about those that we can’t have confidence in our own clinical judgement.


About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in BMJ, BMJ 2010, BMJ 341, Cardiovascular, Clean Living, Medication, Neurology, Osteoporosis. Bookmark the permalink.

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