As we kick off 2011, we have already started to mimic the mantra of the 1970s Temptations’ hit Ball of Confusion. Already the information flowing from the scientific journals has presented disparate data concerning proper ICD implantation, dual-antiplatelet therapy and whether clinical decision support (CDS) systems are up to par.
The most shocking, perhaps, is that more than 20 percent of patients who received ICDs did not meet evidence-based guideline. And while guidelines do not recommend that ICDs be used for primary cardiac sudden death prevention in patients who had a previous MI or CABG surgery, more than 25,000 of the 110,000 patients implanted with ICDs during the study period were non-evidence-based indications.
However, commentaries suggest that these high figures could be somewhat attributable to a lack of documentation and that some patients may fall into a “gray area,” where data suggest that ICDs may be helpful but not recommended by guidelines.
Similarly, the DINAMIT study showed that a reduction in sudden death in ICD patients was offset by increased non-arrhythmic deaths, which occurred most frequently in patients receiving shock therapy. Dr. Sweeney told us that these shocks are toxic in some heart failure patients and could increase the risk of death.
Another study this week in AJC shows that patients may be confused on the importance of continuing dual-antiplatelet therapy after a stenting procedure. The study showed that of the over 400 patients who received stents, 66 discontinued drug therapy and 102 had issues with adherence.
The researchers urged that more education is needed to relay the importance of continuing dual-antiplatelet therapy to thwart off the risk of stent thrombosis.
Other news this week outlines the pros and cons of clinical decision support systems. While one study this week found that use of CDS systems can help reduce inappropriate medical imaging—CT and MRI— another found that the CDS may not always properly discover drug-to-drug interactions.
But even the researchers who found that the CDS may help reduce imaging exams say that the data is limited and that previous studies have shown that while there were decreases in the rate of increased image utilization, actual imaging utilization still grew.
While physicians might have different views about which treatment may be right for each patient, one of the keys going forward is better physician and patient education regarding guidelines and therapy compliance. While the Temptations sang " Where the world's headed nobody knows," with new research and treatment strategies it looks like the medical field can only improve.
Any comments would be welcomed.