Annals for Educators - 4 December 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives4 December 2018Annals for Educators - 4 December 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201812040 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsDiagnosis of Pulmonary Embolism During Pregnancy. A Multicenter Prospective Management Outcome StudyPregnant women are at increased risk for venous thromboembolism (VTE), and pulmonary embolism (PE) is among the most common causes of maternal death. Yet, evidence on the evaluation of suspected PE during pregnancy is limited, prospective management studies have not been reported, and guidelines vary. This prospective multicenter study validated a diagnostic strategy in pregnant women with suspected PE.Use this study to:Ask your learners what symptoms would prompt consideration of PE in a pregnant patient. What is the differential diagnosis?How would your learners approach the diagnosis of PE in a pregnant patient? Would their approach differ from that for a nonpregnant patient? In what ways, and why?Review the results of this study. Do your learners consider the rates of VTE during follow-up among patients managed according to the study's algorithm sufficiently reassuring to adopt the approach?How would your learners have handled study participants who did not have PE at presentation but received prophylactic or therapeutic anticoagulation during the study? How might their inclusion in or exclusion from the analysis influence the results? How did the authors approach this issue, and why?Comparative Effectiveness and Safety of Bariatric Procedures for Weight Loss. A PCORnet Cohort StudyTo compare weight loss up to 5 years after bariatric procedures as well as acute adverse events, this study analyzed data from 41 health systems in the National Patient-Centered Clinical Research Network. The researchers compared outcomes in patients who had Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding procedures.Use this study to:Ask your learners what advice they give to patients with obesity. If they do, how do they raise the subject of weight loss? Are there constructive approaches to such discussions and approaches that are potentially hurtful?When should bariatric surgery be considered? What criteria are used to decide whether surgery is appropriate? Invite a specialist in bariatric medicine or a bariatric surgeon to join your discussion. Ask what procedures are available and what considerations influence the choice for each patient.What are the potential benefits of surgery? Are there benefits beyond weight reduction? Use the accompanying editorial to help frame your discussion. What are the potential acute and chronic complications of bariatric surgery?Use of High-Sensitivity Cardiac Troponin for the Exclusion of Inducible Myocardial Ischemia. A Cohort StudyAlthough guidelines recommend against routine surveillance cardiac stress testing for patients with known, stable ischemic heart disease, such testing is frequently performed. This study evaluated whether blood levels of high-sensitivity cardiac troponin can rule out inducible myocardial ischemia in patients with stable coronary artery disease (CAD).Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how they monitor patients with previously diagnosed CAD. How are “stable” and “unstable” CAD defined?Is “routine” or “surveillance” cardiac stress testing indicated in patients with stable CAD? Why or why not? The authors note that guidelines recommend against it. Is this common practice at your center nonetheless?How might the findings of this study be useful? What more needs to be known for the results of this study to alter clinical care? Use the accompanying editorial to help frame your discussion. Are these results applicable to patients with unstable angina, with or without known CAD?In the Clinic: Fall Prevention in Community-Dwelling Older AdultsOne in 3 adults aged 65 years or older and 1 in 2 adults aged 80 years or older fall each year. Interventions for prevention have been identified; however, they are often not addressed in primary care practice. Do your learners work to prevent falls?Use this review to:Ask your learners whether they consider fall prevention in their usual care of patients. Why or why not?Who is at increased risk for falls? Create a list of intrinsic and extrinsic factors that increase a patient's risk. Use the Box: Intrinsic and Extrinsic Risk Factors for Falls.How might a patient's fear of falling influence his or her quality of life?How should your learners evaluate a patient's risk for falls and the variables that might contribute to increased risk?What home safety recommendations should your learners provide to patients?Are there interventions (exercise, pharmacologic, or others) that can help reduce the risk for falling?Is the risk for falls evaluated for hospitalized patients at your institution? Who does this, and how? What is done when a patient is at increased risk? Is it effective? How do you know? Invite someone from your institution's quality improvement group to discuss how your institution approaches these issues.Use the multiple-choice questions to introduce topics for discussion with your learners, and be sure to log on to enter your answers to earn CME/MOC credit for yourself!Just for FunAnnals Graphic Medicine – Sign OutTake a minute's break to enjoy the latest Annals Graphic Medicine.Humanism and ProfessionalismOn Being a Doctor: Pass It OnDr. Morris recalls the treatment of medical students by some senior members of the team and wonders, “…does it make us feel better to make those around us feel worse? Do we heal our own wounds by inflicting them on others?”Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe. Consider whether you should discuss this essay with your whole team, or separately with those who are and those who are not medical students.Ask your team's members to consider whether they reach out or make gestures to junior members of the team to help them feel welcome, included, and valued.On Being a Doctor: The Hands of an Angel“…I believe with abiding certainty that in that first frightened, hopeful, elated, grief-stricken week in July, nearly half a century ago, I was touched by the hands of an angel.”Use this essay to:Find a quiet spot to listen to an audio recording of this essay with your team, read by Dr. Michael LaCombe. Allow time for quiet after the reading.Ask your learners if they have ever experienced things they cannot explain in the care of patients.How have such experiences affected them?MKSAP 18 QuestionA 75-year-old woman is evaluated during a routine visit. Medical history is significant for hypertension and coronary artery disease with placement of a stent in the mid right coronary artery 5 years ago. She is symptom free. Medications are metoprolol succinate, lisinopril, aspirin, and atorvastatin.On physical examination, temperature is normal, blood pressure is 130/80 mm Hg, pulse rate is 72/min, and respiration rate is 16/min. BMI is 23. The precordial cadence is irregularly irregular. The remainder of the examination is unremarkable.An electrocardiogram shows atrial fibrillation.Which of the following is the most appropriate treatment?A. Add clopidogrelB. Add oral anticoagulationC. Discontinue aspirin and begin clopidogrel and oral anticoagulationD. Discontinue aspirin and begin oral anticoagulationE. No change in therapyCorrect AnswerD. Discontinue aspirin and begin oral anticoagulationEducational ObjectiveManage antithrombotic therapy in a patient with atrial fibrillation and coronary artery disease.CritiqueThis patient with coronary artery disease (CAD) and atrial fibrillation should be treated with oral anticoagulation alone. Thromboembolism (stroke or systemic embolism) is the most feared and devastating complication of atrial fibrillation. Patients with atrial fibrillation and a moderate to high risk for stroke (CHA2DS2-VASc score ≥2) should be treated with oral anticoagulation for stroke prevention. This patient has a CHA2DS2-VASc score of 5 (1 point each for female sex, hypertension, and vascular disease; 2 points for age ≥75 years) and should receive oral anticoagulation therapy. Dose-adjusted warfarin is an effective low-cost option for stroke prevention in patients with atrial fibrillation. The chief limitations of warfarin are the need for frequent INR monitoring and adjustment as well as the numerous food and drug interactions associated with its use. The FDA has approved several non–vitamin K antagonist oral anticoagulants for the prevention of stroke in patients with nonvalvular atrial fibrillation, including dabigatran, rivaroxaban, edoxaban, and apixaban. These agents are superior, or at least noninferior, to warfarin in the prevention of stroke in patients with nonvalvular atrial fibrillation and do not necessitate routine coagulation monitoring. Warfarin remains the agent of choice in patients with valvular atrial fibrillation.Antiplatelet therapy with aspirin is typically indicated in patients with CAD; however, aspirin alone or dual antiplatelet therapy (aspirin plus clopidogrel) is insufficient for stroke prevention in patients at high risk, such as this one.Combination therapy with oral anticoagulation and antiplatelet therapy, such as aspirin or clopidogrel, is associated with significantly increased risk for bleeding and no apparent incremental benefit. This patient already has several risk factors for bleeding, including a low BMI, hypertension, and female sex, and it is important to minimize the risk for bleeding when oral anticoagulation is prescribed. In patients with atrial fibrillation and CAD, it is recommended that antiplatelet therapy be discontinued unless the patient has recent active CAD, defined as acute coronary syndrome or revascularization in the past 12 months. Because this patient has a history of percutaneous coronary intervention performed 5 years ago, there is no indication for concomitant antiplatelet therapy with oral anticoagulation.Key PointFor most patients with high-risk atrial fibrillation and stable coronary artery disease, oral anticoagulation therapy without an antiplatelet agent is sufficient for prevention of both acute coronary syndromes and thromboembolism.BibliographySteinberg BA, Kim S, Piccini JP, Fonarow GC, Lopes RD, Thomas L, et al; ORBIT-AF Investigators and Patients. Use and associated risks of concomitant aspirin therapy with oral anticoagulation in patients with atrial fibrillation: insights from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) Registry. Circulation. 2013;128:721-8. doi:10.1161/CIRCULATIONAHA.113.002927Do 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 4 December 2018Volume 169, Issue 11Page: ED11KeywordsAntiplatelet therapyAspirinAtrial fibrillationFallsOral antiplatelet therapyPatientsPregnancyStable coronary artery diseaseStrokeWeight loss ePublished: 4 December 2018 Issue Published: 4 December 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...