In the past 4 posts, I have shown that systemic RX for stable coronary artery disease (meds) do as well as focal RX (stents). That data had very little effect on actual practice. Why? Watch this:
Reminds me of the recent Norwegian screening colonoscopy study. 80k+ participants with no improvement in primary outcome of CRC deaths. And yet, there's a $1000 bill waiting in the cecum for a willing and able GI doc.
Look what Ai gets you...essentially the narrative from the interventionalist's spin (from that time)
========================================
The RITA-2 trial (Randomized Intervention Trial of Unstable Angina 2) was a clinical trial conducted to compare two treatment strategies for patients with unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI). The trial aimed to evaluate the outcomes of an early invasive strategy (angiography and revascularization if appropriate) versus a more conservative strategy (medical therapy with selective invasive strategy based on recurrent symptoms or stress testing).
Here are the key findings and implications of the RITA-2 trial:
Invasive vs. Conservative Strategy: The trial found that an early invasive strategy was associated with a significant reduction in the composite endpoint of death or myocardial infarction at one year compared to the conservative strategy.
Benefits of Invasive Strategy: The early invasive strategy was particularly beneficial in reducing the rate of myocardial infarction. It also showed a trend toward reducing the need for hospitalization for angina or recurrent ischemia.
No Mortality Benefit: While the invasive strategy led to better clinical outcomes, there was no significant difference in overall mortality between the two groups at one year.
Cost-Effectiveness: The trial also assessed the cost-effectiveness of the two strategies and found that the early invasive strategy was cost-effective in terms of quality-adjusted life years gained.
Subgroup Analyses: Subgroup analyses showed consistent benefits of the invasive strategy across different patient subgroups.
Clinical Implications: The RITA-2 trial indicated that, for patients with unstable angina and NSTEMI, an early invasive strategy was associated with better clinical outcomes compared to a more conservative approach. The trial contributed to the evolving understanding of the management of acute coronary syndromes and influenced clinical practice guidelines.
Limitations: As with any trial, there were limitations, including potential biases and differences in patient populations and healthcare systems that might impact the generalizability of the results.
John, with all these posts about what does not seem to work, even though cardiologists keep doing PCI, what are the studies that recommend interventions that have the best evidence base?
I've just discovered you sensible guys. For me, the JUPITER statin trial trumps everything I've seen, John. It is so full of spin on so many fronts that it should become a textbook case study for doctors, students and medical journalists (are there any left?). I'm happy to share my layman's analysis if you're interested
John’s excellent article supports why I stopped reading any paper printed in Lancet 30 years ago. How could they allow any such conclusion to be printed based on the data presented?
My only comment is that as our language has become co-opted and corrupted by certain special interests, it becomes easier for people in all areas to use weasel words and weasel techniques to twist things to suit those who would like to confuse and gaslight others.
I’d forgotten about this study. It was so long ago I wasn’t even a fellow yet. I think the most striking thing is really in what the Lancet allowed with language. Of all the revisions typically involved btw submission and publication, it is shocking that such an egregious conclusion statement was allowed to stand in light of the underlying data.
Most clinical "medicine" is not evidence/science based. It used to be driven by physician belief/tradition/preference. It is now driven by the economic incentives of the medical-industrial complex. I respect and admire the ethical Cassandras (like you John) who call out the mis/disinformation and prescribe a better way. They are mostly ignored (if not punished) by the system, and patients suffer the ill effects of business as usual. Sad.
Thanks for your passionate and excellent writing John! 👏
I agree it is a big part of the problem. And as I posted above:
Don't forget the utopians. Those who plant seeds that cannot deliver the perfect goal and have negative and often devastating consequences. Are you old enough to recall the 5th vital sign of the 1990s? I recall the push
starting in ernest in the 1980s. The Joint Commission, reimbursement penalties, certification threats and
such. (A pain free world is just a pill away, smh. But hey, it is all just big pharma and money. Right?)
Humans do human things. Look at the efforts to block the high-school to jail cycle that resulted in the Parkland shooting (read "Why Meadow Died"). Just one example of the impact the non scientists or pseudo scientists have on the science of our world under the guise of science.
I had a brief 'discussion' (uncommonly pleasant disagreement) with a scientist ("biologist") recently. He was in total disagreement with my claim that there are serious problems in our science research literature and especially so, medical research papers. I pointed to the failures in the "peer review" process that compounds it. He claimed peer review was awesome and no problems existed.
He also claimed kid in the 6, 7 8 and 9 age groups were more mature, rational and capable of understanding and dealing with topics like gender and sex and such. He considered age restrictions on books in elementary schools as bans. He made great points about how bans and restrictions don't w or. I didn't have a chance to get into his thoughts on gun conyrol policies and laws. Opps.
Good observations. The blatant spin is outrageous, but all too common when the researchers need to please their masters -- drug or device company. One would think that journal editors would demand unbiased language, but they are in on the act as well.
I approach articles with the highest level of skepticism, and usually conclude that the researchers are beholden to their paymasters, and are thus untrustworthy. Other non-financial biases are also pervasive, for example when our public health officials want to promote a narrative and cite cherry-picked and trivial flawed observational studies as the basis of a recommendation such as public masking as an epidemic control. I believe that there is often a higher order bias as well: for instance most nutrition researchers push the "fat is bad" narrative, because "this just seems to make sense", and has been the main stream story for decades. PURE study results that confound the evils of dietary fat are then dismissed in much the manner that the cardiac researchers push for PTCA because of a "minimal increased risk" of a bad outcome.
Hello John, the guest post on JUPITER you suggested is finished - which address should I send it to? kim@musclesandmarbles.com.au
Reminds me of the recent Norwegian screening colonoscopy study. 80k+ participants with no improvement in primary outcome of CRC deaths. And yet, there's a $1000 bill waiting in the cecum for a willing and able GI doc.
Look what Ai gets you...essentially the narrative from the interventionalist's spin (from that time)
========================================
The RITA-2 trial (Randomized Intervention Trial of Unstable Angina 2) was a clinical trial conducted to compare two treatment strategies for patients with unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI). The trial aimed to evaluate the outcomes of an early invasive strategy (angiography and revascularization if appropriate) versus a more conservative strategy (medical therapy with selective invasive strategy based on recurrent symptoms or stress testing).
Here are the key findings and implications of the RITA-2 trial:
Invasive vs. Conservative Strategy: The trial found that an early invasive strategy was associated with a significant reduction in the composite endpoint of death or myocardial infarction at one year compared to the conservative strategy.
Benefits of Invasive Strategy: The early invasive strategy was particularly beneficial in reducing the rate of myocardial infarction. It also showed a trend toward reducing the need for hospitalization for angina or recurrent ischemia.
No Mortality Benefit: While the invasive strategy led to better clinical outcomes, there was no significant difference in overall mortality between the two groups at one year.
Cost-Effectiveness: The trial also assessed the cost-effectiveness of the two strategies and found that the early invasive strategy was cost-effective in terms of quality-adjusted life years gained.
Subgroup Analyses: Subgroup analyses showed consistent benefits of the invasive strategy across different patient subgroups.
Clinical Implications: The RITA-2 trial indicated that, for patients with unstable angina and NSTEMI, an early invasive strategy was associated with better clinical outcomes compared to a more conservative approach. The trial contributed to the evolving understanding of the management of acute coronary syndromes and influenced clinical practice guidelines.
Limitations: As with any trial, there were limitations, including potential biases and differences in patient populations and healthcare systems that might impact the generalizability of the results.
Do have an email I can send it to?
John, with all these posts about what does not seem to work, even though cardiologists keep doing PCI, what are the studies that recommend interventions that have the best evidence base?
There aren’t
I've just discovered you sensible guys. For me, the JUPITER statin trial trumps everything I've seen, John. It is so full of spin on so many fronts that it should become a textbook case study for doctors, students and medical journalists (are there any left?). I'm happy to share my layman's analysis if you're interested
I agree. JUPITER was a piece of work.
Write us a guest post.
Happy to do that, John. Have to get a few things out of the way, but should be OK by the weekend.
John’s excellent article supports why I stopped reading any paper printed in Lancet 30 years ago. How could they allow any such conclusion to be printed based on the data presented?
My only comment is that as our language has become co-opted and corrupted by certain special interests, it becomes easier for people in all areas to use weasel words and weasel techniques to twist things to suit those who would like to confuse and gaslight others.
"trust the science" is a refrain more dystopian the more I read
This is the type of content that destroys confidence in medicine. Stents seem to be the leeches and "bad air" of the 21st century.
I’d forgotten about this study. It was so long ago I wasn’t even a fellow yet. I think the most striking thing is really in what the Lancet allowed with language. Of all the revisions typically involved btw submission and publication, it is shocking that such an egregious conclusion statement was allowed to stand in light of the underlying data.
Why did the Lancet editors allow the authors to get away with this spin? Because it's the Lancet.
Most clinical "medicine" is not evidence/science based. It used to be driven by physician belief/tradition/preference. It is now driven by the economic incentives of the medical-industrial complex. I respect and admire the ethical Cassandras (like you John) who call out the mis/disinformation and prescribe a better way. They are mostly ignored (if not punished) by the system, and patients suffer the ill effects of business as usual. Sad.
Thanks for your passionate and excellent writing John! 👏
I agree it is a big part of the problem. And as I posted above:
Don't forget the utopians. Those who plant seeds that cannot deliver the perfect goal and have negative and often devastating consequences. Are you old enough to recall the 5th vital sign of the 1990s? I recall the push
starting in ernest in the 1980s. The Joint Commission, reimbursement penalties, certification threats and
such. (A pain free world is just a pill away, smh. But hey, it is all just big pharma and money. Right?)
Humans do human things. Look at the efforts to block the high-school to jail cycle that resulted in the Parkland shooting (read "Why Meadow Died"). Just one example of the impact the non scientists or pseudo scientists have on the science of our world under the guise of science.
I had a brief 'discussion' (uncommonly pleasant disagreement) with a scientist ("biologist") recently. He was in total disagreement with my claim that there are serious problems in our science research literature and especially so, medical research papers. I pointed to the failures in the "peer review" process that compounds it. He claimed peer review was awesome and no problems existed.
He also claimed kid in the 6, 7 8 and 9 age groups were more mature, rational and capable of understanding and dealing with topics like gender and sex and such. He considered age restrictions on books in elementary schools as bans. He made great points about how bans and restrictions don't w or. I didn't have a chance to get into his thoughts on gun conyrol policies and laws. Opps.
John,
Good observations. The blatant spin is outrageous, but all too common when the researchers need to please their masters -- drug or device company. One would think that journal editors would demand unbiased language, but they are in on the act as well.
I approach articles with the highest level of skepticism, and usually conclude that the researchers are beholden to their paymasters, and are thus untrustworthy. Other non-financial biases are also pervasive, for example when our public health officials want to promote a narrative and cite cherry-picked and trivial flawed observational studies as the basis of a recommendation such as public masking as an epidemic control. I believe that there is often a higher order bias as well: for instance most nutrition researchers push the "fat is bad" narrative, because "this just seems to make sense", and has been the main stream story for decades. PURE study results that confound the evils of dietary fat are then dismissed in much the manner that the cardiac researchers push for PTCA because of a "minimal increased risk" of a bad outcome.
Frustratingly eye-opening