Friday, February 26, 2010

So far carotid endarterectomy looks better than carotid stenting

"So far" here means according to the results of the interim analysis of the International Carotid Stenting Study (ICSS) surgery looks better. This trial has enrolled 1713 with symptomatic carotid artery stenosis to either endarterectomy or stenting with the major outcome of interest to be the three year outcome of fatal or disabling stroke.

The interim analysis focused on the 3 month comparison of the rate of stroke,death and procedural myocardial infarction in the two groups.The endarterectomy group experienced 27 such events versus 34 in the stenting group or 8.5 % versus 5.2%.

The authors offered this closing sentence:

Completion of long-term follow-up is needed to establish the efficacy of carotid artery stenting compared with endarterectomy. In the meantime, carotid endarterectomy should remain the treatment of choice for patients suitable for surgery.

A earlier trial ( see here) in France also demonstrated the apparent superiority of surgery over carotid stenting.This was the EVa-3s trial which was stopped early for reasons of futility and safety.

For what it is worth the latest Medical Knowledge Self-Assessment Program MKSAP 15 says this about symptomatic ,severe (greater than 70%), carotid artery stenosis:

"carotid endarterectomy is still considered the gold standard..". (One may wonder why a retired internist is still ordering and reading MKSAP)

If I had to decide today in regard to my own neck I would opt for surgery .Of course, I live in an area populated with a large number of excellent, well experienced vascular surgeons and hospitals in which a lot of vascular surgery is performed.

ADDENDUM: (2/26/2010 1:00pm CST)
On the other hand maybe things might be a bit different in North American.The CREST trial results were just reported and seemingly stenting fares better but still not better than endarterectomy overall. Are American stentists more adept? Is comparative effectiveness research (CER) easy or what?

Tuesday, February 23, 2010

Why is the Avandia issue being raised again?

Dr.Mintz offers a good re-review of the literature behind the controversy regarding rosiglitazone (Avandia).
Avandia has been in the news again. See here. Dr. Mnitz says there is nothing new regarding data accumulation or analysis. So why are we hearing about it again. Why are Senators Grassley and Baucus stirring the pot again?

Any thoughts?

Sunday, February 14, 2010

If medical care costs "too much" easy fix is price controls?

The Massachusetts health care plan facing costs greatly in excess of previously advertised ( fantasied?) cost projections can be fixed, according to a proposal by the governor of Mass. The answer is government controlled prices.See here for a new report on that development.

Wage and price controls predictably leads to several things:
poor quality, shortages and black markets.

The Medicare price controls have lead to the first two in regard to primary care.See here for an earlier rant on how price controls has worked out in regard to Medicare.

Thursday, February 11, 2010

Statins in drinking water? not quite yet, but CRP for lots of folks?

The JUPITER trial was a great boost for Crestor and the use of the hs CRP and now the FDA gives approval for wider use of at least one statin.See here for FDA information. Dr. Mintz,as is often the case, offers his thoughtful insights to this issue here.

It has been a while since JUPITER was completed so if you want a review and a very detailed discussion of many of the related issues go here to read what DrRich had to say.

I will shamelessly repeat what I wrote earlier:

"You can talk about the fact that Jupiter was terminated prematurely, you can talk about relative risk versus absolute risk reduction and Crestor effect versus class effect but in the end here is the way things seems to work. When you have a large randomized clinical trial that demonstrates a benefit for a given medication and when many well known medical thought leaders endorse it and when it is then approved by the FDA you know that guidelines will be written and quality rule driven medical practitioners will follow and many patients will take the medication and likely insurance companies will pay for some or all of it.So in this case many folks will have their hs-crp checked and they will be prescribed Crestor ( a few will be given lower price statin cousins) and there will be- for a while- talk about crp at parties."