High-Dose Influenza Vaccine Effectiveness against Hospitalization in Older Adults

* High-Dose Influenza Vaccine to Reduce Hospitalizations

* Efficacy of high-dose versus standard-dose influenza vaccine in older adults

Beta-blockers after myocardial infarction: effects according to sex in the REBOOT trial

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Today on the podcast, I am joined by Dr. Jennifer Rusiecki. Dr. Rusiecki is an Associate Professor of Medicine at the University of Chicago. She is the Director of Women’s Health and Gender-Based Care in the internal medicine residency program and the assistant clinic director overseeing gender-based care.

Dr. Rusiecki and I discussed the article appraised in the other post today, and also discussed the issues of screening for breast cancer in women with dense breasts and breast cancer screening more generally. Dr. Rusieki and I don’t agree on everything, and you might leave more confused than you came, but I still think it is worth a listen.

Some further reading:

The infographic on mammography we discussed.

A recent article on mammogram quandaries.

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A Conservative Dialysis Strategy and Kidney Function Recovery in Dialysis-Requiring Acute Kidney Injury: The Liberation From Acute Dialysis (LIBERATE-D) Randomized Clinical Trial

Beta-Blockers after Myocardial Infarction with Normal Ejection Fraction

* Should Evidence Come with an Expiration Date?

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No video this week — we had a bit of a computer meltdown — but two interesting articles.

As always, thanks for listening. If you have articles you would like us to cover, please send us a suggestion at [email protected].

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In a lifetime of possible memories, only some are accessible. There are a few comments — made by mentors, co-residents, and patients — that have lingered and shaped my medical practice.

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I was shocked at the comments on this post.

Many people, some of them I know to be smart, thought I was nuts for suggesting two middle-aged women who had isolated high LDL-C needn’t take meds because their calculated 10-year risk was less than 3%

What shocked me is that our guidelines suggest treatment with statins when 10-year risk is ≥ 7.5%. You may not know this but clinicians are supposed to consider cholesterol (and BP) based on overall risk, which include things like age, blood pressure, smoking status as well as HDL. Here is a link to the PCE. It drives me bananas that clinicians don’t go over this with patients. They just look at LDL-c in isolation.

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Experts chose this a 7.5% threshold because they felt it was the point where the absolute risk reduction from statins (about 20-25% relative risk reduction) for nonfatal cardiac events outweighed any potential downsides of statins. It is an arbitrary threshold.

The thinking: We know from many RCTs that statins reduce future risk by about 20-25% over 5 years. So .25 x the estimated risk outputs the absolute risk reduction. Let’s say a person has a calculated risk of 10%. They can expect a 2.5% risk reduction (.25 x 10% = 2.5%) over 10 years. But .25 x 3% = .75, so a person with an estimated risk of 3% who takes a daily pill for 10 years goes to 2.25%. That’s not much.

Here are some pics of the pushback I recieved:

My colleagues rightly point out that atherosclerosis of the coronary arteries is a slow process and longer exposure to lower LDL-c is beneficial. They feel that the 10-year horizon is too short. They cite something called Mendelian randomization studies which find that people who were born with genetic profiles that cause low cholesterol also have low rates of heart attacks.

I wrote a post about this. I actually think that statins and blood pressure drugs may have greater effects in younger people who are at lower risk.

But come on. Both individuals who I helped calculate risk were below 3%. That’s too low to worry about.

Further, if you think we treat people with elevated LDL levels who have this low of a risk, why do we need risk calculators? Or…why don’t we just treat everyone above a certain age, since age is the largest driver in the calculators?

These are issues I spoke with Drs Foy and Murthy about. I learned a ton. I hope you will too.

Topics include:

* The value of risk calculators

* The uncertainty of prediction

* The best time window to consider (statin trials were for 5 years; can we assume effect sizes over 5 years are similar at 30 years?)

* The causal role of LDL-c vs “metabolic health”

* The value of coronary artery calcium testing

* Lipoprotein (a)

Academic people like to make fun of podcasts, but I can’t imagine a more educational 40 minutes. Andrew and Venk are two of the most thoughtful people in cardiology today.

Enjoy and consider supporting Sensible Medicine

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Medical Management and Revascularization for Asymptomatic Carotid Stenosis

Vagus nerve-mediated neuroimmune modulation for rheumatoid arthritis: a pivotal randomized controlled trial

We spent quite a bit of time talking about blinding. This is the table on the adequacy of blinding from the supplement. It does seem like blinding was less than perfect.

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We try to answer the remainder of your AUA questions. We will be back in the new year with more article discussions!

Here are a few of the things we referenced.

GDMT Bugs Me: A bit of a rant against the standard of care

A Plan to Refocus Primary Care

Sacrificing patient care for prevention: distortion of the role of general practice

The Great Colonoscopy Debate

Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear

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We cover questions from Amy J, Benjamin Hourani, Diana Stiles Friou, Chris Costas, Errol Laurie, Jim Healthy, Elizabeth Fama, Never Dull, Rod Rodriguez, Ellison Burns, David Araujo, and George.

We have more to come!

One nice reference I found while looking into some of the topics:

DMSO Is Not a Cure-All. But the FDA’s Panic Over It Birthed a Myth

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Vascular and inflammatory diseases after COVID-19 infection and vaccination in children and young people in England: a retrospective, population-based cohort study using linked electronic health records

Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial

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