The Skeptical Cardiologist tackles a ten-dollar word to boost quality of life The Skeptical Cardiologist saw a patient recently who had undergone stenting of a 95% blocked right coronary artery. Mr. Jones had presented a year ago to our ER 2 days after he first began experiencing a light pressure-type discomfort in his left shoulder and scapular region. This pain persisted, waxing and waning, without a clear relationship to exertion or position or movement of his shoulder. Upon arrival in the ER, his ECG was normal but his cardiac enzymes were slightly elevated (troponin peaking at 0.92). Thus, he was diagnosed with a non-ST elevation myocardial infarction (MI). He's done great since the stent procedure fixed the coronary blockage that caused his infarct and chest pain, but during our office visit he related that he had been feeling "logy" since his hospitalization. Being a lover of words, my ears perked up at this new-to-me adjective, and I asked him to describe what he meant by logy. For him, loginess was a feeling of fatigue or lacking energy. Indeed, the online Merriam-Webster dictionary defines logy as sluggish or groggy. It is pronounced usually with a long o and a hard g. The origin is unclear but has nothing to do with rum: "Based on surface resemblance, you might guess that 'logy' (also sometimes spelled 'loggy') is related to 'groggy,' but that's not the case. 'Groggy' ultimately comes from 'Old Grog,' the nickname of an English admiral who was notorious for his cloak made of a fabric called grogram -- and for adding water to his crew's rum. The sailors called the rum mixture 'grog' after the admiral. Because of the effect of grog, 'groggy' came to mean 'weak and unsteady on the feet or in action.' No one is really sure about the origin of 'logy,' but experts speculate that it comes from the Dutch word log, meaning 'heavy.' Its first recorded use in English, from an 1847 London newspaper, refers to a 'loggy stroke' in rowing." Fatigue is a common, nonspecific symptom that we all feel at times. It is more common as we age and it can be challenging for both patients and physicians to sort out when it needs to be further evaluated. Occasionally, fatigue is the only symptom of a significant cardiac condition, but more frequently in the patient population I see it is either noncardiac (low thyroid, anemia, etc.) or iatrogenic. When patients tell me they are feeling fatigued I immediately scan their med list for potential logigenic drugs. In this case, my patient had been started on a low dosage of the beta-blocker carvedilol (Coreg) after his stent. I suspected this was why he had felt logy for the past year. In cardiology, we utilize beta-blockers in many situations -- arrhythmias, heart failure, and heart attacks to name a few -- and they are well-known to have fatigue as a common side effect. There was a really good chance that Mr. Jones's loginess was due to the carvedilol. It's important to review all medications at each patient visit to check for side effects, interactions and benefits, and in the case of Mr. Jones' carvedilol, loginess. Always Needed Post-Revascularization or Post-MI? Beta-blockers (BBs) are frequently started in patients after a stenting procedure or coronary bypass surgery and continued indefinitely. However, the evidence for their benefit in such patients with normal left ventricular (LV) function long term is lacking. If any post-revascularization population benefits from BBs, it is those, like Mr. Jones, who have had an MI prior to the procedure. However, the smaller the infarct, the smaller the benefit. And with the widespread use of early stenting to treat MI, infarcts are much smaller and dysfunction of the left ventricle less likely. In those patients with minimal damage and normal LV function, the benefits appear minimal. For this reason, in the last 5 to 10 years I've been stopping BBs in this population if there are any significant side effects. An "Expert Analysis" published by the American College of Cardiology in 2017 noted: "In patients receiving prompt revascularization or thrombolytics in addition to antiplatelet agents, ACE [inhibitors], and aggressive lipid-lowering therapy, the mortality benefit of beta-blockers post-MI seen in the pre-reperfusion era is likely attenuated. The substrate itself of a reperfused, viable myocardium is sure to behave differently and confer different clinical outcomes. By avoiding myocardial necrosis and scar formation with contemporary management strategies in ACS [acute coronary syndrome], the benefit of beta-blockers in preventing sudden cardiac death via scar-based reentrant arrhythmias is attenuated." In a study of almost 180,000 patients post MI with normal LV systolic function in the U.K. from 2007 through 2013, there was no difference in mortality at 1 year in patients discharged with or without beta-blockers. The only way to answer this question definitely would be with a randomized controlled trial and, to my surprise and delight, such a study -- CAPITAL-RCT (Carvedilol Post-Intervention Long-Term Administration in Large-scale Randomized Controlled Trial) -- was published in PLoS One in August 2018. I'll save readers the details, but the bottom line is that patients treated with optimal contemporary therapy for acute MI whose LV function was not significantly impaired did not benefit in any way from treatment with carvedilol, the beta-blocker my patient was taking. It's rare that we get such definitive evidence for a change in treatment that reverses what is in current guidelines. This has the potential to affect tens of thousands of patients and improve their quality of life. It should be trumpeted far and wide. The cynic in me suspects that if it were a study demonstrating the benefits of a new drug, physicians would be bombarded with the new information. Helping Patients Feel Less Logy We will be ordering an echocardiogram on Mr. Jones. If his LV function is normal, we will stop his carvedilol and see if he feels significantly better. I feel like stopping a drug that is not beneficial and that is causing a lifetime of loginess is an incredibly important intervention a cardiologist can make. It's not as life-saving as stenting for acute MI, but saving quality of life is something this non-invasive cardiologist can do every day for every patient. For readers who do want the details on CAPITAL-RCT, here's the summary from the abstract in PLoS One: "... STEMI patients with successful primary PCI within 24 hours from the onset and with left ventricular ejection fraction (LVEF) ≥40% were randomly assigned in a 1-to-1 fashion either to the carvedilol group or to the no beta-blocker group within 7 days after primary PCI. The primary endpoint is a composite of all-cause death, myocardial infarction, hospitalization for heart failure, and hospitalization for acute coronary syndrome. Between August 2010 and May 2014, 801 patients were randomly assigned to the carvedilol group (N = 399) or the no beta-blocker group (N = 402) at 67 centers in Japan. The carvedilol dose was up-titrated from 3.4±2.1 mg at baseline to 6.3±4.3 mg at 1-year. During median follow-up of 3.9 years with 96.4% follow-up, the cumulative 3-year incidences of both the primary endpoint and any coronary revascularization were not significantly different between the carvedilol and no beta-blocker groups (6.8% and 7.9%, P = 0.20, and 20.3% and 17.7%, P = 0.65, respectively). There also was no significant difference in LVEF at 1-year between the 2 groups (60.9±8.4% and 59.6±8.8%, P = 0.06)." Source
