The 2 Minute Medicine Podcast Episode 52

In the first half of this episode we cover our article of the week which comes from  the New England Journal of Medicine and is entitled “Invasive Treatment Strategy for Older Patients with Myocardial Infarction.“

In the second half, we start with a discussion about Jamie Foxx’s hemorrhagic stroke that led to his 2023 hospitalization. Then we take a closer look at how paracetamol might have a more serious side-effect profile than previously believed. After that, we examine the battle between the FDA and vaping in the Supreme Court. Finally, we discuss the coffee and tea’s protective effects against head and neck cancer..

Click here to listen to this episode on Apple podcast

Click here to listen to this episode on Spotify

Transcript

[Deepti] Welcome to the 2 Minute Medicine Podcast, summarizing the latest medical studies, curated and written by practicing physicians.

For our full suite of daily medical study summaries and updates written by practicing doctors, please visit our website at 2minutemedicine.com to start reading new daily content right now, for free. On this podcast, twice a month, we cover the latest in health care news and research evidence. We are your hosts Deepti and Andrew. On today’s episode, we’ll start off by discussing our two articles of the week. In the second half of the episode, we will look at health issues that have arisen in popular media. 

[Andrew] Our article of the week comes from the New England Journal of Medicine and is entitled “Invasive Treatment Strategy for Older Patients with Myocardial Infarction.“

Advancing age is an established risk factor for NSTEMI. Despite this, older adults have been repeatedly underrepresented in clinical trials; consequently, no established treatment guideline remains for this population. To date, the small number of clinical trials investigating the use of invasive treatment in older adults with NSTEMI have yielded conflicting results; some suggest its superiority, while others negate this claim. Furthermore, the poor characterization of frailty, cognitive capabilities, and coexisting conditions in older adults within these studies limits their generalizability. This randomized controlled trial sought to evaluate the effectiveness of a routine invasive approach to NSTEMI in older adults compared to best-standard medical treatment in a study population representative of the general public. The invasive strategy included coronary angiography with possible coronary revascularization in addition to the best medical practices, while the conservative approach involved the best medical practices alone. Patients were eligible if they were over 75 years old with a confirmed NSTEMI diagnosis. Exclusion criteria included a diagnosis of STEMI, unstable angina, or cardiogenic shock; a life expectancy under one year; prior participation in the SENIOR-RITA trial; or an inability to undergo coronary angiography.

A total of 753 patients were randomized to the invasive strategy and 765 to the conservative strategy. The primary outcome was time to a composite event of cardiovascular death or nonfatal MI. Over a median follow-up of 4.1 years, 25.6% of patients in the invasive group and 26.3% in the conservative group experienced a primary outcome event (hazard ratio, 0.94; 95% Confidence Interval [CI], 0.77 to 1.14; p=0.53). On average, patients in the invasive strategy group had 29 additional days free from a primary outcome event over five years compared to those in the conservative group (95% CI, -40 to 98). Interestingly, invasive treatment was associated with a higher rate of cardiovascular death (hazard ratio, 1.11; 95% CI, 0.86 to 1.44) but a lower rate of nonfatal MI (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Additionally, while the invasive approach resulted in fewer strokes (hazard ratio, 0.81; 95% CI, 0.51 to 1.28), it doubled the incidence of TIA (hazard ratio, 2.05; 95% CI, 0.92 to 4.56). Patients treated with invasive therapy were also less likely to undergo further coronary angiography (hazard ratio, 0.20; 95% CI, 0.14 to 0.28) and coronary revascularization (hazard ratio, 0.26; 95% CI, 0.17 to 0.39). The procedure was generally safe, with complications occurring in less than 1% of patients. The results indicate that invasive therapy does not significantly lower the composite risk of cardiovascular death or nonfatal MI. While not statistically significant, patients treated with an invasive strategy had fewer occurrences of fatal or nonfatal MI or stroke and required fewer coronary angiography or revascularization interventions. Conversely, the invasive-strategy group experienced higher rates of all-cause death, non-cardiovascular death, transient ischemic attacks (TIAs), and bleeding that required medical attention. This study had several limitations, including a smaller sample size than initially planned due to recruitment challenges during COVID-19. Overall, the findings suggest that invasive treatment is not superior to the best medical practices for managing NSTEMI in older adults. In conclusion, these findings suggest that invasive treatment is not superior to optimal medical therapy alone in managing older adults with NSTEMI. 

[Andrew] Next, let’s take a look at the Scan. 

The Story: On December 10, 2024, Jamie Foxx returned to stand-up comedy with Jamie Foxx: What Had Happened Wasand shared the details behind his 2023 health scare. The American actor and comedian revealed his hospitalization between April 2023 and May 2023 was due to a “brain bleed that led to a stroke”.

Let’s take a closer look at what strokes are and why they happen. 

[Deepti] A stroke is a medical emergency that occurs when blood flow to the brain is disrupted (ischemic stroke) or when there is sudden bleeding in the brain (hemorrhagic stroke). The latter contributes to 10-20% of strokes and can be further classified into intracerebral hemorrhage (ICH), where the bleed occurs within the brain tissue itself, and subarachnoid hemorrhage (SAH), where the bleed occurs in the subarachnoid space, an area between layers of tissue separating the skull and brain. In both cases, the extra blood puts pressure on and damages brain cells. Common causes of hemorrhagic stroke include trauma, hypertension, ruptured or malformed blood vessels, clotting disorders, and masses. In this case, actor did not share whether he had an ICH or an SAH but did reveal doctors are still unsure what caused his stroke. His medical scare also demonstrates the hidden dangers of brain bleeds. Foxx’s headache, the most common symptom, was dismissed by the first doctor he saw, who sent him home with a cortisone shot. Doctors warn to be wary of a sudden, severe headache accompanied by neurological deficits such as blurry vision, facial droop, weakness, or speech changes.

 How long does it take to recover?

Prognosis depends on the underlying cause and bleed characteristics such as size and location. Even then, stroke rehabilitation, which seeks to improve neurological and functional capacity, is highly variable, lasting months to years, and many patients unfortunately never fully recover. Jamie Foxx woke up on May 4, 2023, in a wheelchair with no recollection of his last 20 days. He has fully recovered after a year of neurological and physical rehabilitation and is back to acting and comedy. His next film, Back in Action, scheduled for release Jan. 17, 2025, is a fitting name.

[Andrew]: Acetaminophen (paracetamol), more commonly known as Tylenol, is one of the most widely used medications in the world. With dozens of generic versions of Tylenol, acetaminophen’s market size was valued at an astonishing $10.83 billion in 2024. It is many people’s initial medication of choice for fever, muscle aches, and all sorts of pain.

 However, a November 2024 study examined the incidence of acetaminophen side effects and found the medication to be more harmful than commonly perceived, contributing to previous findings that suggest acetaminophen use in older patients requires reconsideration. The cohort study looked at over 500,000 adults ≥65 years in the United Kingdom and found patients with acetaminophen exposure (at least two acetaminophen prescriptions within six months) were at increased risk of perforation or ulceration or bleeding (PUB), uncomplicated peptic ulcers, lower gastrointestinal (GI) bleeding, heart failure, myocardial infarction, hypertension, and chronic renal failure compared to unexposed patients.

 Due to its perceived safety, many doctors recommend acetaminophen as a first-line medication for older patients with osteoarthritic pain. However, the authors argue that these results combined with the fact that acetaminophen has relatively weak analgesic effects suggest there may actually be a minimal positive or even negative risk-benefit ratio for its use in older adults. While further research is needed to confirm the findings, the authors believe acetaminophen guidelines should be revisited.

 [Deepti] On December 2, 2024, the United States (U.S.) Supreme Court heard arguments for the U.S. Food and Drug Administration’s (FDA) rejection of two e-cigarette companies’ flavoured vape products, rejections the companies argue failed to follow proper federal law procedures. The FDA is concerned flavours are attractive to youth and have thus-far only approved 27 e-cigarettes. This marks another escalation of a decades-long battle between the two sides since the introduction of e-cigarettes to the U.S. market in 2007.

 While e-cigarette, or vape, use among high-schoolers has drastically declined from its 2019 peak of 27.5%, 5.9% still report using e-cigarettes, with 87.6% of those users favouring the flavoured variety. Ongoing research, including systematic reviews and large meta-analyses, continues to corroborate and identify new adverse effects of vaping on respiratory, cardiovascular, and neurological systems. E-cigarette use has been shown to increase smoking cessation, although it has also been linked to higher chances of combustible cigarette usage later in life.
The Supreme Court’s ruling is expected by June 2025. However, the FDA’s battle against nicotine addiction won’t end there. Vaping gained widespread cognition and remains popular due to its prevalence in pop culture. Social media, celebrity and influencer use and endorsements, movies, TV shows, and music all contribute to the phenomenon of vaping as a symbol of popularity, edginess, and even art. 

[Andrew] While people drink coffee and tea for their taste or energy boost, new research has found another benefit: potential protective effects against head and neck cancer (HNC). The study, published on Dec. 23, 2024, in Cancer, compiled data on 9,548 HNC cases and 15,783 controls from fourteen case-control studies. Although previous papers have found an inverse relationship between coffee and tea consumption and the reduced risk of HNC, this study highlighted dose-dependent effects on different HNC subsites.

 The authors found that compared to non-coffee drinkers, individuals who drank over 4 cups of caffeinated coffee daily had 17% lower odds of all HNCs, while individuals who drank 3-4 cups daily had a 41% lower risk of developing hypopharyngeal cancer. The study also found inverse relationships between decaffeinated coffee and tea consumption with HNC occurrence. Interestingly, tea consumption was highly dose-dependent, with individuals drinking over 1 cup daily having 38% higher odds of developing laryngeal cancer.

 This doesn’t mean exclusively drinking coffee or tea, which at USD 3.08/cup will certainly harm your wallet. Large quantities of caffeine can cause nervousness, headache, anxiety, or even palpitations and chest pain, and worsen osteoporosis or irritable bowel syndrome. A single tea bag can release billions of microplastics into the body and may increase the risk of gastroesophageal reflux disease, potentially explaining the increased likelihood of developing laryngeal cancer.

[Andrew] Thank you for joining us today for this episode of the 2 Minute Medicine Podcast. New episodes come out every other week and all of our content has been curated and written by practicing physicians.

We would like to thank Alex Xiang, Michaela Dowling, Keira Liblik for contributing to this week’s episode

New episodes come out every other week and all of our content has been curated and written by practicing physicians.