Annals for Hospitalists - 21 May 2019
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2019)

Web Exclusives21 May 2019Annals for Hospitalists - 21 May 2019FREEDavid H. Wesorick, MD* and Vineet Chopra, MD, MSc*David H. Wesorick, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this author and Vineet Chopra, MD, MSc*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO201905210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesHow I Treat: Catheter-Related Deep Venous Thrombosis—Vineet Chopra, MD, MScWith growing use of peripherally inserted central catheters, catheter-related upper-extremity deep venous thrombosis is becoming a more common occurrence. In this article, an expert clinician describes his approach to managing this condition.Highlights of Recent Articles from Annals of Internal MedicineIn the Clinic: HypertensionAnn Intern Med. 2019;170:ITC65-80. doi: 10.7326/AITC201905070This article discusses new recommendations for hypertension management derived principally from the 2017 guidelines issued by the American College of Cardiology and the American Heart Association.Key points for hospitalists include:Blood pressure (BP)–lowering medications are now recommended for all patients with BP 140/90 mm Hg or higher and for patients with BP 130/80 to 139/89 mm Hg who also have diabetes, chronic kidney disease (stage 3 or higher), clinical cardiovascular disease, or an estimated 10-year risk for atherosclerotic cardiovascular disease of 10% or higher.First-line antihypertensive medications include thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and-calcium channel blockers. Chlorthalidone or indapamide are recommended over hydrochlorothiazide by most experts because of their greater potency and duration and better clinical outcomes. β-Blockers are not a first-line choice for most patients unless specifically indicated to treat a comorbid condition.Patients with resistant hypertension (i.e., BP still not at goal despite treatment with 3 antihypertensive medications) should be assessed for secondary causes of hypertension. Spironolactone is recommended for many patients with this condition because it is more effective than β-blockers or α-blockers in these patients (many patients with resistant hypertension have hyperaldosteronism).Ideas and Opinions: Raising the Bar for Procedural Competency Among HospitalistsAnn Intern Med. 2019;170:654-5. Published on 23 April 2019. doi:10.7326/M18-3007This article explores how hospitalists are trained and assessed for procedural competency, and the process by which hospitals grant procedural privileges. The authors argue that many hospitalists are undertrained to perform hospital procedures, many hospitalists do not perform an adequate volume of procedures to maintain competence, and many hospitals grant privileges based on an inadequate assessment of a hospitalist's skills.Key points for hospitalists include:No national standard outlines how hospitalists should be trained or how procedural competence should be demonstrated. This leads to interhospital variability in practice and use of non–evidence-based standards (e.g., employing an arbitrary number of procedures per year as a “measure” of competence).Many procedural skills wane as a result of low procedural volumes, and most hospitals do not have established mechanisms to ensure that hospitalists maintain their skills.The authors make several suggestions about how to rectify this problem. These include development of mandatory simulation-based procedure training programs, consolidating procedural responsibilities in select groups of “proceduralists” (to allow a subset of hospitalists to maintain adequate procedural volumes), and developing national standards for procedural competence assessment for hospitalists.The Latest Highlights From Journal ClubIs dual antiplatelet therapy beneficial after minor ischemic stroke or transient ischemic attack?Guideline: Starting dual antiplatelet therapy ≤ 24 h after high-risk TIA or minor ischemic stroke is recommendedAnn Intern Med. 2019;170:JC38. doi: 10.7326/ACPJ201904160-038This clinical practice guideline, based on a systematic review of the literature (3 randomized controlled trials, n = 10 447), makes recommendations about dual antiplatelet therapy (DAPT) after minor ischemic stroke or high-risk transient ischemic attack. The authors suggest that DAPT should be started for most patients who have these conditions within 24 hours of the ischemic event. The use of DAPT during this high-risk period seems to reduce recurrent, nonfatal stroke more than aspirin alone. Adverse effects include a possible increase in moderate to severe bleeding, which can be minimized if DAPT is discontinued after 10 to 21 days (with aspirin continued alone thereafter).Is catheter ablation of atrial fibrillation better than medical management in patients with heart failure?Review: In adults with AF and HF, AF catheter ablation vs drug therapy reduces mortality and HF hospitalizationsAnn Intern Med. 2019;170:JC43. doi: 10.7326/ACPJ201904160-043This meta-analysis included 6 RCTs (n = 775) that compared catheter ablation of atrial fibrillation (AF) with medical therapy for patients with heart failure (HF). Patients undergoing catheter ablation had lower rates of all-cause mortality and fewer hospitalizations for heart failure. The results were driven predominantly by the largest of the included RCTs.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Disclosures:Drs. Wesorick and Chopra have disclosed no conflicts of interest. The forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.* The authors are co-first authors and contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - How I Treat—Catheter-Related Deep Venous Thrombosis Vineet Chopra Metrics 21 May 2019Volume 170, Issue 10Page: HO10KeywordsCardiac ablationCathetersHospitalistsHospitalizationsHypertensionIschemic strokeMortalityResistant hypertensionTransient ischemic attacksTreatment guidelines ePublished: 21 May 2019 Issue Published: 21 May 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.Loading ...