Download Are beta-blockers more effective for rate control than calcium

(36% vs 2.7%; mean difference [MD] 33%; 95% CI,
19%–47%; P<.00001). However, results were no longer
statistically significant at 18 weeks from initiation of the
study (55% vs 30%; MD 25%; 95% CI, –23% to 82%;
P=.27). Additionally, when comparing proportion of
ulcers with complete resolution of wound area between
groups after 18 weeks, no significant difference was
noted for HBOT (risk ratio [RR] 5.0; 95% CI, 0.28–90;
P=.28) compared with room air.2
Joshua Layher, DO
Bethany Teer, MD
Madigan Army Medical Center
Tacoma, WA
The opinions and assertions contained herein are those of the authors and
are not to be construed as official or as reflecting the views of the US Army Medical
Department, the US Army at large, or the Department of Defense.
1. Kranke P, et al. Cochrane Database Syst Rev. 2012; (4):CD004123. [STEP 2]
2. Hammarlund C, et al. Plast Reconstr Surg. 1994; 93(4):829–833. [STEP 2]
randomized sequence. The 24-hour heart rate was
measured using Holter monitoring.
Mean heart rate over 24 hours was 96 beats/min
at baseline (no treatment), 75 beats/min with diltiazem,
81 beats/min with verapamil, 82 beats/min with
metoprolol, and 84 beats/min with carvedilol. The
24-hour heart rate was significantly lower with diltiazem
than with any other drug tested (P<.001; individually
for each other drug). Some limitations of this study were
the small sample and that patients with ischemic heart
disease or systolic heart failure were not included.2
The evidence-based guidelines of the American
College of Cardiology Foundation/American Heart
Association Task Force state that beta-blockers or
calcium channel blockers alone or combined with
digitalis are the drugs of choice for rate control in
patients with atrial fibrillation.3
Are beta-blockers more effective for rate control
than calcium channel blockers in patients
with atrial fibrillation?
Evidence-Based Answer
It is unclear if beta-blockers are better than calcium
channel blockers for outpatient rate control in patients
with atrial fibrillation. Guideline recommendations
state either option is acceptable (SOR: B, evidencebased guideline).
An RCT with more than 2,000 adults with atrial
fibrillation (AFib) compared the effectiveness of calcium
channel blockers versus beta-blockers with or without
digoxin.1 Patients randomized to rate control were
given rate-controlling drugs chosen by their treating
physicians. The average follow-up was 3.5 years.
Overall rate control (resting heart rate
<80 beats/min) was achieved in more patients given a
beta-blocker as the first drug (with or without digoxin)
compared with patients started initially on a calcium
channel blocker (with or without digoxin) (70% vs
54%; P<.0001). Limitations of this study were that
neither the patient nor investigator was blinded to the
study drugs.1
A prospective, randomized, investigator-blind
crossover study (N=60) compared 4 drug regimens used
to reduce the ventricular heart rate in patients with
permanent AFib.2 Diltiazem, verapamil, metoprolol,
and carvedilol were administered for 3 weeks in a
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Evidence-Based Practice / August 2014
Monika Kumanova, MD
Jose Tiburcio, MD
Bronx Lebanon Hospital Center FPRP
Bronx, NY
1. Olshansky B, et al. J Am Coll Cardiol. 2004; 43(7):1201–1208. [STEP 2]
2. Ulimoen SR, et al. Am J Cardiol. 2013; 111(2):225–230. [STEP 2]
3. Fuster V, et al. J Am Coll Cardiol. 2011; 57(11):e101–e198. [STEP 1]
What are the risks and benefits of screening
for cerebral aneurysm in patients with a firstdegree relative dying of cerebral aneurysm?
Evidence-Based Answer
Patients with first-degree relatives who died from a
cerebral aneurysm have an increased risk for cerebral
aneurysm. However, whether screening should be
done is unclear because a full understanding of the
risks and benefits of early intervention is lacking (no
SOR given).
In a Markov-Monte Carlo simulation model study, the
cost effectiveness of screening for cerebral aneurysms
was evaluated.1 Assumptions made in the study included
that (1) the rate of aneurysm development is constant
through life, and (2) the rate of aneurysm rupture
is constant in time. Ten-year risk of subarachnoid
hemorrhage (SAH) in individuals with a family history
of SAH was estimated at 7% and lifetime risk of SAH
in individuals with 2 affected first-degree relatives
was estimated to be 26%. Incidence of aneurysm
development was estimated to be 0.3% to 0.7% per
year. Rate of rupture was estimated to be 1% to 2%
per year.
The model revealed that screening was cost effective
when compared with the cost of care after an SAH. The
model proposed screening at-risk individuals 20–80 years
old with a 7-year screening interval. This approach would
provide 0.25 quality-adjusted life-years (QALY) and the
cost/QALY would be $19,296. The authors commented
that the risks associated with screening were dependent
on the outcomes of preventive surgical intervention,
for which data are lacking. The authors recognized the
limitations of a simulation model and proposed that
screening be individualized to each patient.1
In a prospective cohort trial involving 303 patients
who had 2 or more first-degree relatives who died of
SAH secondary to cerebral aneurysm, the authors
sought to improve screening strategies by identifying
patient characteristics that confer a “high-risk”
status.2 The method of screening used was magnetic
resonance angiography. Patients were recruited from
North America, New Zealand, and Australia. They
came from families with multiple members diagnosed
with intracranial aneurysms. The exclusion criteria
were presence of fusiform intracranial aneurysms; an
intracranial aneurysm with arteriovenous malformation;
and family history of polycystic kidney disease, EhlersDanlos syndrome, Marfan syndrome, fibromuscular
dysplasia, or moyamoya syndrome. The incidence of
cerebral aneurysm was found to be 19% and the annual
rupture rate was 2%. Within the trial group, those with
1 or more aneurysms were compared to those without
an aneurysm.
Independent predictors of aneurysm detection
included female sex (OR 2.5; 95% CI, 1.5–4.5),
>20 pack-years of cigarette smoking (OR 3.2; 95% CI,
1.8–5.8), and duration of hypertension >10 years (OR
1.3; 95% CI, 1.1–1.5). During the 10-month followup, no mortality benefit from screening was shown. The
authors reported intent to provide long-term followup to further assess the natural history of aneurysms
identified in this patient population.2
In a small prospective cohort trial involving
95 Turkish patients with first-degree relatives affected
by cerebral aneurysms, the incidence of cerebral
aneurysm was 9.4% and the size of the aneurysm had
a statistically significant correlation with likelihood
of aneurysmal rupture (nonruptured aneurysms mean
diameter, 4.5 mm; and ruptured aneurysms mean
diameter, 5.9 mm; P=.025).3 This article did not discuss
the risks and benefits of screening.
Brandon Hecht, DO
Lanier Adams, DO
Dwight D. Eisenhower Army Medical Center
Fort Gordon, GA
The opinions and assertions contained herein are those of the authors
and are not to be construed as official or as reflecting the views of the US Army Medical
Department, the US Army at large, or the Department of Defense.
1. Bor AS, et al. Neurology. 2010; 74(21):1671–1679. [STEP 5]
2. Brown RD Jr, et al. J Neurosurg. 2008; 108(6):1132–1138. [STEP 3]
3. Goksu E, et al. Turk Neurosurg. 2012; 22(1):55–61. [STEP 3]
How accurate is screening for recurrence
of ovarian cancer with CA-125?
Evidence-Based Answer
In patients with persistently elevated CA-125 levels,
a CA-125 that either doubles from the upper limit of
normal (ULN) or doubles from the nadir can accurately
predict ovarian cancer recurrence after initial treatment
(SOR: B, consistent cohort trials).
A 1996 retrospective cohort trial analyzed periodically
drawn CA-125 levels and clinical recurrence of ovarian
cancer over a 12-month period to determine the level
predictive of relapse in 255 women with stage Ic-IV
ovarian cancer after treatment with carboplatin or
cisplatin.1 A total of 131 patients were considered in the
final analysis. The gold standard for disease recurrence
was clinical or imaging-proven disease progression.
A rise in CA-125 level to 2×ULN had a sensitivity
of 85% and a specificity of 91% (positive likelihood
ratio [LR+] 9.4; negative likelihood ratio [LR–] 0.16). If
a subsequent CA-125 level was drawn for confirmation,
the sensitivity decreased to 84% and specificity increased
to 98% (LR+ 42; LR– 0.16).1
A 2001 retrospective analysis on 88 patients who
had clinical or radiological evidence of recurrent ovarian
cancer and persistently elevated CA-125 levels after
treatment was performed to determine CA-125 levels
that predicted recurrence.2 Clinical signs were the gold
standard for disease recurrence. If clinical signs were
inadequate for diagnosis, radiological confirmation was
obtained. CA-125 levels that rose to twice that of the
nadir value gave a sensitivity of 79% and a specificity
of 67% (LR+ 2.4; LR– 0.31).
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