Prophylaxis of Genital Herpes Recurrences with Antivirals

SOURCE: Sands-Lincoln M, Goldmann DR. Antiviral drugs to prevent clinical recurrence in patients with genital herpes. Am J Med 2016;129:1264-1266.

For now, herpes has outsmarted us. Antivirals can reduce the duration of acute attacks, decrease the number of days of viral shedding, and reduce the frequency of recurrences, but they do not eradicate the latent virus or alter the natural course of disease. Once antiviral treatment ends, the frequency and severity of attacks resumes unaltered.

However, the good news is that the three currently approved antivirals (acyclovir, famciclovir, valacyclovir) can produce a major, albeit imperfect, effect on recurrences when administered daily as prophylaxis. The literature suggests recurrences can be reduced by as much as 70-80% in patients presenting with frequent recurrences.

Long-term data (one to six years) support the safety and efficacy of the antivirals, each of which has demonstrated similar benefit.

In the absence of head-to-head clinical trials, no substantial differences in efficacy or tolerability among the three potential treatments have been demonstrated.

Our experience with antivirals against influenza has taught us that problematic levels of resistance can occur quickly, but similar trends for genital herpes have not been observed.


Atrial Fibrillation Still a Mortal Disorder

SOURCE: Fauchier L, Villejoubert O, Clementy N, et al. Causes of death and influencing factors in patients with atrial fibrillation. Am J Med 2016;129:1278-1287.

The advent of warfarin for anticoagulation in patients presenting with atrial fibrillation (AF) provided dramatic risk reductions; more than 60% reduced risk of ischemic stroke, and more than 25% reduced mortality. The addition of novel anticoagulants (factor Xa and antithrombin agents) reduces risk even more.

It may come as a surprise that of the 5.5% annual risk of death noted in a population of AF patients, the three most common causes of death were heart failure (29%), infection (18%), and cancer (12%).

Of course, anticoagulation does not totally eliminate stroke-related deaths in AF, not only because not all strokes may be caused by other disorders besides AF, but also because utilization of anticoagulants, particularly warfarin, also is imperfect.

Stroke and bleeding remain less frequent, but nonetheless important, causes of death in the AF population studied (n = 7,668), each accountable for 7% of deaths.

Although we have much to celebrate in the efficacy of established and novel treatments for stroke prevention in AF, the authors proposed that we might pay greater attention to prevention, identification, and management of heart failure, as it is the most frequent cause of death in patients presenting with AF.


Identifying Risk for Macrovascular Events in Diabetes Patients

SOURCE: Mohammedi K, Woodward M, Zoungas S, et al. Absence of peripheral pulses and risk of major vascular outcomes in patients with type 2 diabetes. Diabetes Care 2016;39:2270-2277.

Cardiovascular disease is the most common cause of death for patients suffering from type 2 diabetes. Even though it is also common for type 2 diabetes patients to suffer from dyslipidemia and hypertension, the cardiovascular disease risk is disproportionate to these burdens. How might we better identify type 2 diabetes patients who are at particularly high risk?

Creators of the ADVANCE trial enrolled type 2 diabetes patients (n = 11,120) and compared tight vs. standard glucose control for cardiovascular disease outcomes. However, the authors were unable to confirm any macrovascular benefit of tight control.

At enrollment into ADVANCE, researchers sought and recorded peripheral pulses (dorsalis pedis and posterior tibial, bilaterally) on physical exam.

Over a median of five years of follow-up, absence of either pulse predicted increased risk for myocardial infarction, stroke, cardiovascular death, heart failure, and all-cause mortality.

The absence of either of the pulses had similar predictive value, and risk of adversity increased with the number of missing pulses.

Diabetic patients deserve our best efforts to prevent, forestall, or mitigate cardiovascular events. The simple clinical maneuver of peripheral pulse palpation can help us identify a subgroup of type 2 diabetes patients who are at measurably increased risk.