Annals for Educators - 21 August 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives21 August 2018Annals for Educators - 21 August 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201808210 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsHypertensive Disorders of Pregnancy and Maternal Cardiovascular Disease Risk Factor Development. An Observational Cohort StudyWomen with a history of hypertensive disorders of pregnancy (HDPs) are more likely to develop cardiovascular disease (CVD) than those who are normotensive during pregnancy. Guidelines recommend that clinicians evaluate CVD risk by screening for a history of HDPs, but data on which risk factors to screen for and the frequency and timing of screening are lacking. This study examined the associations of gestational hypertension and preeclampsia with development of chronic hypertension, type 2 diabetes, and hypercholesterolemia among a sample of women from the Nurses' Health Study II.Use this study to:Start a teaching session with multiple-choice questions. We've provided 2 below!Ask your learners to name potential HDPs.How frequently should blood pressure be monitored during pregnancy? What blood pressure readings warrant concern, and what should be done? How are gestational hypertension and preeclampsia diagnosed? Do your learners know how these are managed?What do we know about the risk for CVD among women with a history of an HDP? Do your learners ask about this history? Does it alter how they monitor their parous patients?Review the design and results of this study. What prepregnancy cardiovascular risk factors were accounted for in the analysis? Why weren't prepregnancy blood pressure, lipid, and glucose values accounted for? Why does that matter?How does this limitation affect what this study can tell us about the nature of the relationship between HDPs and future CVD? Do HDPs per se contribute to the increased CVD risk, or do they simply identify women who have “failed” the cardiometabolic stress test of pregnancy because of a preexisting increased propensity for CVD? Use the accompanying editorial to help frame your discussion. Should the results of this study alter when your learners evaluate cardiovascular risk factors in their patients who have a history of an HDP?Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons. A Cohort StudyVenous thromboembolism, ischemic stroke, and myocardial infarction in transgender persons may be related to hormone use. The electronic medical records of Kaiser Permanente sites in Georgia and northern and southern California were examined to compare the risk for these events among transgender versus cisgender persons.Use this study to:Ask your learners what medical treatments may be used to align their patients' physical appearance with their gender identity.What risks may be increased by the hormone treatments used? Why might cardiovascular outcomes specifically be affected? Are there other potential risks?What did this study find regarding the risk for venous thromboembolism among transfeminine persons compared with cisgender women and cisgender men? Do these results fit with what your learners know about the risks associated with these hormones when they are used for other indications?Where can patients find expert transgender medicine care in your area?When Tissue Is No Longer the Issue: Tissue-Agnostic Cancer Therapy Comes of AgeMatching unique features of cancer types with effective therapies is a cornerstone of precision medicine. Recent advances have found that the success of biomarker-driven cancer therapy may be relevant across sites of origin. Several large, ongoing clinical trials with a “basket” design are combining tumor tissue genomics with potential off-the-shelf therapies in drug development, and more tissue-agnostic biomarker therapies are reaching the bedside.Use this study to:Ask your learners what the implications are of chemotherapeutic agents that target cell processes common to both normal and malignant cells. Ask your learners to list examples of “tissue targeting” in current chemotherapies for cancer (for example, HER2 in breast cancer or BCR-ABL in chronic myelogenous leukemia).What does a “tissue-agnostic” approach to cancer treatment mean? How does this differ from an approach based on the histologic origin of a tumor?What is a basket trial?Assign members of your team to read the succinct examples of applying a tissue-agnostic approach (for example, BRAF inhibition in melanoma and lung cancer or immune checkpoint blockade for cancers with mismatch repair deficiencies). Have them explain what they read to the rest of the team.Invite an oncologist to discuss how these approaches are altering oncologic practice.Video LearningAnnals Consult Guys – PE in Pregnancy: What Imaging? What Drugs?In this episode of the consultative medicine talk show, Geno and Howard address the tricky topic of venous thromboembolism during pregnancy.Use this feature to:Ask your learners how they would approach the evaluation of a pregnant patient with concern about possible venous thromboembolism.Then, take a break with your learners to watch the short video.Answer the short multiple-choice questions with your team. Be sure to log on and enter your own answers to earn CME/MOC credit for yourself!Humanism and ProfessionalismOn Being a Patient: What Once WasLyra is your hero. Funny, sad, nine and three quarters Lyra. She is the child in you who never grew up, and she watches as the magic potion goes drip, drip, drip into the tube that snakes into your chest.Use this essay to:Listen to an audio recording of the essay, read by Dr. Virginia Hood. Ask your learners who Lyra is.Ask if Lyra's presence makes things easier or harder to bear.Ask your learners whether they have ever asked their patients how they deal with their challenges and fears as they embark on medical care. Are there patients on your service who might appreciate telling you and would be willing to do so?On Being a Doctor: To Walk in Another's ShoesThe objective facts told Dr. Lu that her patient should not be given opioids, but her heart told her differently.Use this essay to:Listen to an audio recording of the essay, read by Dr. Virginia Hood. Have your learners ever been torn about doing what seemed medically correct when their heart was saying to do something else?How do we decide whether to deviate from what we think is, strictly speaking, the medically appropriate path? When is it appropriate to act as Dr. Lu did when patients request opioids?What can we do in such situations to minimize the risks?Do your learners believe they are able to look past what seems an inappropriate request for opioids to see the person and story behind the request? Do we fear doing so?MKSAP 17 Question 1A 35-year-old woman is evaluated during a follow-up visit. She is at 37 weeks' gestation of her first pregnancy. Preeclampsia was diagnosed at 32 weeks when she was found to be hypertensive with mild proteinuria; she was previously normotensive. Her subsequent prenatal obstetric and laboratory monitoring has remained stable, and she is without symptoms. Medical history is otherwise unremarkable, and her only medication is a prenatal vitamin.On physical examination, temperature is 36.9 °C (98.4 °F), blood pressure is 148/85 mm Hg, pulse rate is 87/min, and respiration rate is 12/min. BMI is 27. Examination of the lungs and heart is normal. The abdomen shows expected changes of pregnancy but is otherwise normal. There is trace bipedal edema. The remainder of the examination is unremarkable.Laboratory studies are significant for a normal platelet count, blood urea nitrogen, serum creatinine, electrolyte panel, and liver chemistry studies.Which of the following is the most appropriate next step in management?A. Antihypertensive therapyB. Aspirin therapyC. Delivery of the babyD. GlucocorticoidsE. Continued monitoring until termCorrect AnswerC. Delivery of the babyEducational ObjectiveManage preeclampsia.CritiqueThe most appropriate next step in management is delivery of the baby in this woman with preeclampsia without features of severe disease. Preeclampsia is classically defined as new-onset hypertension after 20 weeks of pregnancy with proteinuria (≥300 mg/24 h or a urine protein-creatinine ratio ≥300 mg/g). Delivery of the baby is the definitive treatment for preeclampsia. In patients with preeclampsia and severe disease, generally defined as severe hypertension (systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg), thrombocytopenia (platelet count <100,000/µL [100 × 109/L]), kidney dysfunction (serum creatinine concentration >1.1 mg/dL [97.2 µmol/L] or doubling of the serum creatinine concentration in the absence of other kidney disease), impaired liver function (elevated blood concentrations of liver aminotransferases to twice the normal concentration), pulmonary edema, or cerebral or visual symptoms, management decisions are usually made based on the balance of fetal and maternal risk with the implications of preterm delivery. In women with preeclampsia without severe features, delivery at 37 weeks has been shown to optimize both maternal and neonatal outcomes (such as fetal growth restriction, abruption placentae, hemorrhage due to thrombocytopenia, seizures, cerebral hemorrhage, pulmonary edema, and kidney injury) and is the most appropriate next step in managing this patient.Treatment of mild hypertension in preeclampsia has not been shown to alter the course of disease or improve fetal outcomes. Therefore, antihypertensive treatment is generally reserved for patients with preeclampsia with severe hypertension, which is not present in this patient.There is evidence that low-dose aspirin therapy may be beneficial in reducing the occurrence of preeclampsia in moderate- to high-risk women. However, it does not have a role in treating preeclampsia or eclampsia.Glucocorticoids are used to accelerate fetal lung maturation if delivery is contemplated before the 34th week of pregnancy but do not directly affect outcomes in preeclampsia. Therefore, their use is not indicated in this patient.Because of the benefit of delivery at 37 weeks' gestation in women with preeclampsia, continued monitoring beyond this time is not optimal.This content was last updated in January 2016.Key PointDefinitive therapy for preeclampsia is delivery of the baby.BibliographySteegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010 Aug 21;376(9741):631-44.MKSAP 17 Question 2A 32-year-old woman is evaluated during a follow-up visit. She is at 12 weeks' gestation of her first pregnancy. Her pregnancy has been uncomplicated except for persistently elevated blood pressures measured at her obstetric visits. She otherwise feels well. She has no urinary symptoms such as dysuria, hematuria, or foamy urine. She did not receive routine medical care prior to her pregnancy. Family history is notable for hypertension in her parents and one older sibling. Her only medication is a prenatal vitamin.On physical examination, temperature is 37.1 °C (98.8 °F), blood pressure is 154/93 mm Hg, pulse rate is 87/min, and respiration rate is 16/min. BMI is 24. Funduscopic and neurologic examinations are normal. Chest and cardiac examinations are normal. Abdominal examination is unremarkable. There is trace lower extremity edema.Laboratory studies show normal liver chemistries and kidney function. A complete blood count is normal except for a hemoglobin level of 10.9 g/dL (109 g/L). Urinalysis is normal.Which of the following is the most likely diagnosis?A. Chronic hypertensionB. Gestational hypertensionC. Normal pregnancyD. PreeclampsiaCorrect AnswerA. Chronic hypertensionEducational ObjectiveDiagnose chronic hypertension in a pregnant patient.CritiqueChronic hypertension is the most likely diagnosis. Hypertension prior to the 20th week of gestation is most consistent with previously undiagnosed chronic hypertension, which may go undetected in healthy women because of a minimal need for medical evaluation prior to pregnancy. As in nonpregnant patients, chronic hypertension may be primary (formerly known as essential) or secondary. This patient presents at the 12th week of gestation with persistently elevated blood pressures since her pregnancy was discovered, suggesting that her hypertension predated her pregnancy, and is likely primary because she has no other clinical features or laboratory study results to suggest a different cause. The 2013 American College of Obstetricians and Gynecologists (ACOG) guidelines recommend treating persistent blood pressure elevations of >160/105 mm Hg in women with chronic hypertension, with a goal blood pressure with medical therapy in these patients being 120-160/80-105 mm Hg.The diagnosis of gestational hypertension requires consistent hypertension after the 20th week of gestation without preexisting hypertension or features of preeclampsia and must resolve within 12 weeks of delivery. Because this patient is persistently hypertensive early in her pregnancy, gestational hypertension is not likely.Normal physiologic changes associated with pregnancy include increased cardiac output and decreased systemic vascular resistance and blood pressure. Blood pressure elevations to the level seen in this patient are not normally seen in pregnancy, when blood pressures are usually much lower.Preeclampsia requires the combination of new-onset hypertension after 20 weeks of pregnancy and end-organ damage such as proteinuria, kidney dysfunction, thrombocytopenia, abnormal liver chemistry tests, pulmonary edema, and cerebral or visual symptoms.This content was last updated in January 2016.Key PointHypertension prior to the 20th week of gestation is most consistent with previously undiagnosed chronic hypertension, which may go undetected in healthy women because of a minimal need for medical evaluation prior to pregnancy.BibliographySeely EW, Ecker J. Chronic hypertension in pregnancy. Circulation. 2014 Mar 18;129(11):1254-61.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 August 2018Volume 169, Issue 4Page: ED4KeywordsAttentionBlood pressureCardiovascular diseasesEdemaHypertensionLiverPreeclampsiaPregnancyResearch laboratoriesVenous thromboembolism ePublished: 21 August 2018 Issue Published: 21 August 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...