<i>Annals</i> for Educators - 21 June 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives21 June 2016Annals for Educators - 21 June 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201606210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsAspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: U.S. Preventive Services Task Force Recommendation StatementAspirin for the Primary Prevention of Cardiovascular Events: A Systematic Evidence Review for the U.S. Preventive Services Task ForceAspirin for the Prevention of Cancer Incidence and Mortality: Systematic Evidence Reviews for the U.S. Preventive Services Task ForceBleeding Risks With Aspirin Use for Primary Prevention in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task ForceThese evidence reviews were used to inform the U.S. Preventive Services Task Force guideline on aspirin use for the prevention of cardiovascular disease and colorectal cancer. The recommendations apply to adults aged 40 years or older without known cardiovascular disease and without increased bleeding risk.Use these papers to:Start a teaching session with a multiple-choice question. We've provided one below.Ask your learners how aspirin works. How does its effect on cyclooxygenase and subsequent molecules relate to the pathogenesis of cardiovascular events? How is aspirin thought to reduce the risk for colorectal cancer? How does aspirin increase the risk for gastrointestinal (GI) bleeding?Review the Task Force's recommendations for using aspirin to prevent cardiovascular disease and colorectal cancer. Ask your learners why the recommendations target, among other criteria, patients willing to take aspirin for at least 10 years.Will your learners recommend aspirin to their patients? Which ones? At what dose? See what an editorialist has to say.The Task Force estimates cardiovascular risk using the ACC/AHA pooled cohort equations but notes the lack of well-validated tools to identify those at heightened risk for GI bleeding. How will your learners evaluate this risk?These reviews and guideline focused on the risk for GI bleeding. What other adverse events may occur with aspirin use?Video LearningThe Consult Guys: Serving Up Advice: A Waiter With HematuriaIn this installment of the consultative medicine talk show, Drs. Merli and Weitz (The Consult Guys) pretend to be a chimney sweep and waiter to discuss the evaluation of hematuria.Use this feature to:Ask your team why a patient's occupation might be relevant in the evaluation of hematuria.Then watch this short video with your team.What is the differential diagnosis of microscopic hematuria? How should patients be evaluated? Do all patients require an evaluation for possible malignancy? Use a recent concise and practical review to prepare.Log in and answer the brief multiple-choice questions associated with this video to earn CME for yourself!Our Health Care SystemEarly Coverage, Access, Utilization, and Health Effects Associated With the Affordable Care Act Medicaid Expansions. A Quasi-experimental StudyLittle is known about the effect of the Medicaid expansions on health care utilization, access to care, and health among persons gaining coverage. The results of this quasi-experimental study suggest that Medicaid expansion seems to be achieving the broad goals of the Patient Protection and Affordable Care Act (ACA).Use this study to:Ask your learners why Medicaid expansion has occurred in some, but not all, states under the ACA. Why does it matter?Why is this study characterized as “quasi-experimental”? The authors used a “difference-in-difference” design to compare changes in patient outcomes in expansion and nonexpansion states before and after the Medicaid expansions. Ask your learners to explain how such an analysis works. How does it help to mimic a randomized trial?Could a randomized trial of Medicaid expansion be performed? Do your learners think it would be ethical?What key questions remain to be answered in assessing the success of Medicaid expansion? Use the accompanying editorial to help frame your discussion.The editorialist notes that until now states' decisions regarding whether to expand Medicaid under the provisions of the ACA have been based largely on opinion rather than fact. Support for (or opposition to) the ACA and its provisions is a divisive political issue. Do your learners feel that they have a role (or responsibility) to play as physicians in this debate? When, and in what ways, is it appropriate to use our “physician title” to interject our opinions?ACP Journal ClubACP Journal Club - 21 June 2016This month's ACP Journal Club concisely critiques important studies of the associations between fluoroquinolone and macrolide antibiotic use and arrhythmias, the risks associated with new-onset atrial fibrillation in patients with myocardial infarction, and more.Use this feature to:Find articles for use at a journal club.You may also search by topic for journal club articles, and ideas on how to use them, at Annals Teaching ToolsAssign members of your team to read a single article summary from ACP Journal Club, and to concisely summarize the key points during teaching rounds. Remind them to pay attention to their chosen study's limitations—an important habit to develop as they learn to read the medical literature.MKSAP 17 QuestionA 55-year-old man is evaluated during a new patient visit. He feels well and has no specific symptoms, but he asks for advice on reducing his risk for cardiovascular disease because his younger brother recently had a myocardial infarction. He leads a sedentary lifestyle but has no cardiopulmonary symptoms. Medical history is significant for obesity and hypertension. Medications are hydrochlorothiazide and lisinopril.On physical examination, he is afebrile, and blood pressure is 136/82 mm Hg. BMI is 34. Waist circumference is 99 cm (39 in). The remainder of the physical examination is normal.Laboratory studies:Alanine aminotransferaseNormalTotal cholesterol207 mg/dL (5.36 mmol/L)LDL cholesterol137 mg/dL (3.55 mmol/L)HDL cholesterol34 mg/dL (0.88 mmol/L)Creatine kinaseNormalSerum creatinineNormalTriglycerides180 mg/dL (2.03 mmol/L)Hemoglobin A1cNormalHis 10-year risk for a major cardiovascular event based on the Framingham risk calculator is 12%.The patient is instructed on lifestyle modifications and is started on moderate-intensity simvastatin.Which of the following is the most appropriate additional treatment for reduction of this patient's cardiovascular risk?A. AspirinB. DiltiazemC. FenofibrateD. MetforminCorrect AnswerA. AspirinEducational ObjectiveReduce cardiovascular risk in a patient with metabolic syndrome.CritiqueAspirin is the most appropriate treatment to reduce cardiovascular risk in this patient with metabolic syndrome. According to the International Diabetes Federation and the American Heart Association (AHA), diagnosis of metabolic syndrome is made by the presence of three or more of the following five criteria: (1) increased waist circumference; (2) serum triglyceride level of 150 mg/dL (1.70 mmol/L) or higher (or taking medications for hypertriglyceridemia); (3) HDL cholesterol level lower than 40 mg/dL (1.04 mmol/L) in men and lower than 50 mg/dL (1.30 mmol/L) in women (or taking medication specifically for low HDL cholesterol); (4) blood pressure of 130/85 mm Hg or higher (or taking antihypertensive medications); and (5) fasting plasma glucose level of 100 mg/dL (5.6 mmol/L) or higher (or taking medications for hyperglycemia). The patient meets at least three criteria (elevated triglyceride level, decreased HDL cholesterol level, antihypertensive treatment). Management of patients with metabolic syndrome should focus on optimizing general health and targeting the individual components of the metabolic syndrome. Lifestyle changes include education on the importance of following a heart-healthy diet, implementing a weight loss plan, and exercising for 30 minutes daily at least 5 days per week. Patients with hypertension should be treated aggressively to achieve the blood pressure goals outlined by the Eighth Joint National Committee. Similarly, dyslipidemia should be treated according to American College of Cardiology (ACC) and AHA cholesterol treatment guideline, and hyperglycemia should be managed per guidelines from the American Diabetes Association. Additionally, the AHA recommends low-dose aspirin for patients with metabolic syndrome with a 10-year cardiovascular risk of 10% or higher. This patient's hypertension and hyperlipidemia are being managed; however, he should also be prescribed aspirin based on his increased risk, provided that his risk for bleeding is not increased.Diltiazem will not provide additional cardiovascular risk reduction in this patient. Moreover, intensification of his hypertension therapy is not indicated, since the blood pressure goal for patients younger than 60 years is a systolic pressure of less than 140 mm Hg and a diastolic pressure of less than 90 mm Hg. The patient's pressures are within this range.Fenofibrate increases the potential for drug-induced side effects and has uncertain additive cardiovascular risk reduction when used with statins, which are clearly indicated in this patient based on ACC/AHA guidelines. Fibrate therapy is reserved for patients with hyperlipidemia who do not tolerate or do not respond to statin monotherapy, patients who have triglyceride levels higher than 500 mg/dL (5.65 mmol/L), or patients with hypertriglyceridemia-induced pancreatitis.The role of metformin in the metabolic syndrome has not been clearly defined. It may reduce the incidence of metabolic syndrome in at-risk patients, but healthy lifestyle modifications are equally effective or superior to metformin in reducing cardiovascular risk. Metformin has also not been shown to reduce cardiovascular events in patients without diabetes. Metformin would be a reasonable choice for both treatment of hyperglycemia and improvement of metabolic parameters if this patient did have impaired fasting glucose or impaired glucose tolerance, and it would be the initial drug of choice if the patient develops diabetes.Key PointPatients with metabolic syndrome who have a 10-year cardiovascular risk of 10% or higher should be treated with low-dose aspirin for primary prevention of cardiovascular disease.BibliographyBlaha MJ, Bansal S, Rouf R, Golden SH, Blumenthal RS, Defilippis AP. A practical “ABCDE” approach to the metabolic syndrome. Mayo Clin Proc. 2008 Aug;83(8):932-41.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 21 June 2016Volume 164, Issue 12Page: ED12KeywordsAspirinBlood pressureCardiovascular diseasesColorectal cancerHemorrhageHigh density lipoproteinHyperglycemiaHypertensionMetabolic syndromePatient Protection and Affordable Care Act ePublished: 21 June 2016 Issue Published: 21 June 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...