1st December 2017, Volume 130 Number 1466

Tiotropium in early-stage chronic obstructive pulmonary disease

Patients with mild or moderate chronic obstructive pulmonary disease (COPD) rarely receive medications, because they have few symptoms. These researchers speculate that long-term use of tiotropium would improve lung function and ameliorate the decline in lung function in such patients.

Eight hundred and forty-one patients were involved in this randomised placebo-controlled trial. Half were treated with a daily inhaled dose of 18 micrograms of tiotropium and the other half a matched placebo. The primary end point was the between-group difference in the change from baseline to 24 months in the forced expiratory volume in one second (FEV1) before bronchodilator use.

Tiotropium resulted in a higher FEV1 than placebo at 24 months and ameliorated the annual decline in the FEV1 after bronchodilator use in patients who had mild to moderate COPD.

N Engl J Med 2017; 377:923–35

Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome

A routine invasive strategy is recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of invasive strategy is less clearly defined.

As individual clinical trials were underpowered to detect benefit, this group undertook a meta-analysis of eight relevant trials. Over 5,000 patients with a median follow-up of 180 days were involved. Overall there was no significant mortality reduction in the early invasive group compared with the delayed invasive group. However, a lower mortality rate was associated with the early invasive strategy in those with elevated cardiac biomarkers at baseline and in those with diabetes or who were 75 years of age or older.

An early invasive strategy does not reduce mortality compared with a delayed invasive strategy in all patients with NSTE-ACS. However, an early invasive strategy might reduce mortality in high-risk patients.

Lancet 2017; 390:737–46

Risk of acute myocardial infarction with NSAIDs in real world use

What are the risks of acute myocardial infarction associated with use of common non-steroidal anti-inflammatory drugs (NSAIDs) under real life practice circumstances?

That is the question addressed in this meta-analysis. A cohort of over 400,000 individuals was acquired from healthcare databases. The onset of risk and effects of duration of use and daily dose were characterised for celecoxib, diclofenac, ibuprofen, naproxen and rofecoxib.

All NSAIDs were associated with an increased risk of acute myocardial infarction. The odds ratio of risk was 1.24 for celecoxib, 1.48 for ibuprofen, 1.50 for diclofenac, 1.53 for naproxen and 1.58 for rofecoxib. The risk was greatest with higher doses and during the first month of NSAID use without obvious further increase with continued use.

BMJ 2017; 357:j1909