Ann Intern Med 3 July 2007 Vol 147

The current fashion in Britain is to put every patient who is thought to need a statin on 40mg of simvastatin. Atorvastatin is a more powerful drug, weight for weight, with a wide dose range. This study compared a dose of 10mg with a dose of 80mg in patients aged 65 or over with stable ischaemic heart disease. There was an absolute difference in cardiovascular events of 2.3% between the groups, which the authors purvey as a strong argument for the high dose. But there was little attempt to quantify adverse events (except biochemically) or cost. A Polypiller would argue that you can get nearly all the benefit for an eighth of the dose.

Whereas statins remain in high favour for protecting the heart, beta-blockers are often relegated to the status of yesterday’s drugs. Not so, according to this pooled analysis of 4 trials using intravascular ultrasonography of the coronary arteries, demonstrating that patients on beta-blockers show no increase in atheroma, whereas the rest show progression. All fine, dandy and very hi-tech, but beta-blockers are a very heterogeneous group of drugs, and have effects on much more that atheroma. Which one should I use to prevent real events, and at what dose?

The gold standard for measuring renal function is the real glomerular filtration rate, measured in this study by a radiolabelling method (iothalamate). But this study of people with chronic renal failure discovered that a better predictor for progression to end-stage failure or death was a simple serum marker – cystatin C. So in both renal failure and heart failure, we have the odd situation that a simple blood test predicts outcomes better than the supposed “gold standard” for direct measurement of function (I am referring to BNP and echographic ejection fraction, in case you hadn’t guessed).
It might be possible to help some people lose weight by the right kind of counselling, but I don’t seem to manage it. More intensive regimes can bring modest improvements for a period of time, according to this meta-analysis of counselling interventions.

Advance directives
are one means by which individuals can try to exert some control over the process of their own dying – but do they work? This discussion piece from the Ecumenical Center for Religion and Health at the University of Texas points out all the potential inadequacies of advance directives in the actual messy business of modern dying. The argument is ostensibly based on Camus’ “existentialism” as illustrated in his novel, The Plague. The author concludes that it is our duty to “bear witness to the patients’ suffering”. Oh no it isn’t. It is to relieve the patient’s suffering. That was what Dr. Rieu in the novel risks his life doing for weeks in the plague-ridden, stifling hospital. He couldn’t do much: but if we can help achieve a death in accordance with a dying patient’s stated wishes, shouldn’t we be allowed to do so?