"Roulette, that's the game now"

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Kaitlyn Dmyterko, staff writer

“Roulette, that's the name now. Roulette, that's the game now,” sang Bruce Springsteen and the E Street Band in Roulette. Sometimes, with the plethora of studies that seemingly contradict each other, one might be tempted to equate choosing one drug or device or modality over another as an either-or decicion, when in fact, it can be complementary.

First, German researchers this week found CT and MRI to be on equivalent in detecting heart disease. In the over 100 patients scanned with CT or MRI, diagnostic accuracy and vessel-based accuracy was more than 80 percent for both modalities. Such data are welcome, given the complex nature of comorbid conditions that might preclude patients from undergoing one or the other exam.

Regarding statins, one meta-analysis suggested that they are not effective or cost effective as primary prevention in low-risk patients, while another showed they are effective in high-risk patients, even those with low levels of C-reactive protein (CRP).

As we move more toward individualized medicine, studies such as these help to parse the data so clinicians can better tailor therapy on a patient-by-patient basis.

Lastly, in the debate surrounding anticoagulants, a study published in the European Heart Journal found that prasugrel (Effient) had greater platelet inhibition and response in type 2 diabetics with coronary artery disease when compared with clopidogrel (Plavix).

Cardiologists are sometimes flummoxed by diabetics and their aggressive response to atherosclerosis. Much research is expended to find ways to better treat their heart disease compared to those without diabetes. We have already seen benefits with prasugrel in PCI compared with clopidogrel in nondiabetic patients. Now we can consider a more tailored approach to diabetics who are poor responders to clopidogrel.

Last March, the FDA slapped a boxed warning onto clopidogrel’s label after it was found that some patients may not actively metabolize the drug and did not receive the drug’s full benefits. However, other P2Y12 inhibitors such as prasugrel and ticagrelor have been shown to decrease mortality after PCI and may be particularly beneficial for STEMI patients.

The research wheel, like the roulette wheel, will continue to spin. In contrast to the casino game, however, medical research produces many winners and few losers. Are you prescribing statins for primary prevention in low risk patients? Do you choose your imaging modalities wisely? Are you giving diabetics the best care? Let us know where your wheel stops.

Kaitlyn Dmyterko
Senior Writer