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Cardiovascular Medicine - Coronary Heart Disease, Stable
Revascularization or medical therapy for ischemic cardiomyopathy (October 2022)
In patients with ischemic cardiomyopathy (ICM), it is unclear whether revascularization of coronary artery disease (CAD) is superior to optimal medical therapy alone. In a trial that included 700 patients with multivessel CAD and reduced left ventricular ejection fraction who were randomly assigned to receive percutaneous coronary intervention (PCI) with optimal medical therapy or optimal medical therapy alone, rates of death or rehospitalization were similar between the groups.2 However, important factors that are commonly used to guide treatment decisions (eg, patient eligibility for coronary artery bypass grafting and correlation between stress testing and clinical findings) were not reported, limiting the trial's broader application to clinical practice. Revascularization is usually indicated for patients with ICM who have signs or symptoms of obstructive CAD, while optimal medical therapy may be appropriate for patients who do not have a clear association between clinical findings and obstructive CAD or who have advanced heart failure.
Family Medicine - Adult General Internal Medicine
Vitamin D trials do not show benefit for COVID-19 outcomes (October 2022)
There is growing interest in the role of vitamin D as a facilitator of the innate immune response during SARS-CoV-2 infection. However, two recent trials evaluating the effect of vitamin D supplementation on COVID-19 outcomes did not show a benefit:
* In a trial from the United Kingdom, in which 6200 adults were randomly assigned to testing of serum 25-hydroxyvitamin D followed by daily low (800 units) or high (3200 units) dose vitamin D supplementation when the concentration was <30 ng/mL (<75 nmol/L) versus no testing/supplementation, there was no difference in the incidence or severity of COVID-19 during six months of follow-up.3
* In a trial from Norway, in which 34,601 adults were randomly assigned to 5 mL of cod liver oil (400 units vitamin D) or placebo daily for six months, there was no difference in the incidence or severity of COVID-19 during six months of follow-up.4
In patients with COVID-19, vitamin D supplementation may be necessary to meet the recommended intake or to treat deficiency; however, doses exceeding the upper-level intake with the intention of improving COVID outcomes are not advised.
Allergy and Immunology - Asthma and COPD
Mepolizumab for childhood asthma in urban under-served populations (October 2022)
Among adults and adolescents with severe eosinophilic asthma, treatment with mepolizumab (a monoclonal antibody to interleukin-5) reduces exacerbation rates; however, data in children are limited. Mepolizumab was compared with placebo in a trial of children and adolescents recruited from low-income, primarily urban environments in the United States who presented with poorly controlled asthma and elevated blood eosinophils. Mepolizumab reduced asthma exacerbation rates compared with placebo in this population (1.0 versus 1.3 per year, relative risk 0.73), but the improvement was less than that observed in prior trials of adults and adolescents (relative risk approximately 0.50).1 Whether this lesser performance is due to ongoing environmental exposure, higher levels of noneosinophilic inflammation, biologic changes between childhood and adult asthma, or other differences in the overall study populations is not well understood.
1. Jackson DJ, Bacharier LB, Gergen PJ, et al Mepolizumab for urban children with exacerbation-prone eosinophilic asthma in the USA (MUPPITS-2): a randomised, double-blind, placebo-controlled, parallel-group trial. Lancet. 2022;400(10351):502. [Context Link]
2. Perera D, Clayton T, O'Kane PD, et al Percutaneous Revascularization for Ischemic Left Ventricular Dysfunction. N Engl J Med. 2022;387(15):1351. Epub 2022 Aug 27. [Context Link]
3. Jolliffe DA, Holt H, Greenig M, et al Vitamin D Supplements for Prevention of COVID-19 or other Acute Respiratory Infections: a Phase 3 Randomised Controlled Trial (CORONAVIT). BMJ. 2022;378:e071230. [Context Link]
4. Brunvoll SH, Nygaard AB, Ellingjord-Dale M, et al Prevention of covid-19 and other acute respiratory infections with cod liver oil supplementation, a low dose vitamin D supplement: quadruple blinded, randomised placebo-controlled trial. BMJ. 2022;378:e071245. Epub 2022 Sep 7. [Context Link]
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