Annals for Hospitalists - 21 April 2020
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2020)

Web Exclusives21 April 2020Annals for Hospitalists - 21 April 2020FREEDavid 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/AWHO202004210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnnals for Hospitalists Inpatient Notes - Inpatient Hypertension—To Treat or Tolerate?—Timothy S. Anderson, MD, MAS, and Charlie M. Wray, DO, MSHospitalists often treat severe hypertension in inpatients by offering extra antihypertensive medication doses or augmenting the home antihypertension regimen. However, the authors of this month's commentary suggest that this practice may be unnecessary and harmful.Highlights of Recent Articles From Annals of Internal MedicineEffectiveness and Safety of Apixaban Compared With Rivaroxaban for Patients With Atrial Fibrillation in Routine Practice: A Cohort StudyAnn Intern Med. 2020;172:463-473. Published 10 March 2020. doi:10.7326/M19-2522This retrospective cohort study used nationwide commercial health care claims data from December 2012 through January 2019 to compare the safety and efficacy of apixaban and rivaroxaban. Patients with atrial fibrillation with new prescriptions for apixaban (n = 39 351) were propensity score–matched to those with new prescriptions for rivaroxaban (n = 39 351) and followed for almost 300 days. Compared with patients prescribed rivaroxaban, patients prescribed apixaban had lower incidence rates of ischemic stroke or systemic embolism (6.6 vs. 8.0 per 1000 person-years) and lower rates of gastrointestinal bleeding or intracranial hemorrhage (12.9 vs. 21.9 per 1000 person-years).Key points for hospitalists include:Among adults with nonvalvular atrial fibrillation, apixaban was safer and more effective than rivaroxaban. This finding aligns with prior indirect comparisons of these medications. Randomized trials directly comparing them are under way.Some confounders (e.g., aspirin use, race, and socioeconomic status) were not measured in this study and may affect its internal validity.Dual Versus Triple Therapy for Atrial Fibrillation After Percutaneous Coronary Intervention: A Systematic Review and Meta-analysisAnn Intern Med. 2020;172:474-483. Published 17 March 2020. doi:10.7326/M19-3763This review examined 4 randomized controlled trials (n = 7953) that compared dual therapy (a direct oral anticoagulant plus a P2Y12 inhibitor) with triple therapy (a vitamin K antagonist plus a P2Y12 inhibitor plus aspirin) in patients with atrial fibrillation and recent percutaneous coronary intervention. The analysis demonstrates high-certainty evidence that dual therapy is associated with a reduced risk for major bleeding compared with triple therapy (risk difference, −0.013 [95% CI, −0.025 to −0.002]). However, although rates of death and ischemic outcomes (e.g., myocardial infarction, stent thrombosis, and stroke) were not statistically significantly different between the groups, wide CIs make a definitive conclusion impossible.Key points for hospitalists include:In patients with atrial fibrillation after percutaneous coronary intervention, this study demonstrates that the use of dual therapy is associated with a lower rate of bleeding than triple therapy, but it cannot conclusively demonstrate that dual therapy is as effective as triple therapy in preventing death and ischemic events.An editorialist suggests that readers “stay tuned,” noting that the antithrombotic decisions in these patients are complex and that ongoing research in this space ensures that practice will continue to evolve.Should You Treat This Acutely Ill Medical Inpatient With Venous Thromboembolism Chemoprophylaxis? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterAnn Intern Med. 2020;172:484-491. doi:10.7326/M20-0347In this discussion, 2 speakers present their thoughts about the use of venous thromboembolism (VTE) prophylaxis in a specific case of a 40-year-old woman who was hospitalized for treatment of inflammatory polyarthritis. The first, a hematologist, suggests that VTE is associated with increased mortality, and after a gestalt risk assessment, decides to prescribe low-molecular-weight heparin for prophylaxis. The second, a hospitalist, states that the benefits of VTE prophylaxis are small, and after applying a formal risk assessment model, recommends withholding prophylaxis.Key points for hospitalists include:VTE is a recognized complication of hospitalization.Prophylactic medical treatments have been shown to effectively reduce the risk for this complication, although in the original trials, much of the benefit was derived from the prevention of asymptomatic thrombi (which are of less certain clinical significance than symptomatic thrombi).The low VTE event rate across all hospitalized patients leads to a high number needed to treat to prevent a VTE event.The ideal approach might be to assess each patient's risk individually and reserve medical prophylaxis for those who are at highest risk. However, this approach is hamstrung by the fact that the available risk assessment models have still not been prospectively validated.The Latest Highlights From Journal ClubFor critically ill patients in the intensive care unit, does early palliative care consultation impact decision making?In high-risk ICU patients, early palliative care consultation increased transition to DNR/DNI statusAnn Intern Med. 2020;172:JC30. doi:10.7326/ACPJ202003170-030This cluster, crossover, randomized, controlled trial involved 233 patients who were admitted to the intensive care unit and identified as being at high risk for morbidity and mortality. The patients were randomly assigned to consultation with an interprofessional palliative care team or usual care. Patients receiving the palliative care consultation had significantly higher rates of transition to do-not-resuscitate/do-not-intubate status and transfer to hospice and significantly lower rates of emergency department visits or readmissions after discharge.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 - Inpatient Hypertension—To Treat or Tolerate? Timothy S. Anderson and Charlie M. Wray Metrics 21 April 2020Volume 172, Issue 8Page: HO8KeywordsApixabanAtrial fibrillationHemorrhageHospitalistsIschemic strokeMyocardial infarctionPalliative carePercutaneous coronary interventionProphylaxisRisk assessments ePublished: 21 April 2020 Issue Published: 21 April 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.Loading ...