Annals for Hospitalists - January 2022
Authors: Megan Mack, Matthew Luzum, David H. Wesorick
Journal: Annals of Internal Medicine (2022)

Web ExclusivesJanuary 2022Annals for Hospitalists - January 2022FREEMegan Mack, MD*, Matthew Luzum, MD*, David H. Wesorick, MDMegan Mack, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (M.M., M.L., D.H.W.)Search for more papers by this author, Matthew Luzum, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (M.M., M.L., D.H.W.)Search for more papers by this author, David H. Wesorick, MDFrom Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (M.M., M.L., D.H.W.)Search for more papers by this authorAuthor, Article and Disclosure Informationhttps://doi.org/10.7326/AWHO202201180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesClinical Pearls—Stopping, Starting, and Optimizing Guideline-Directed Medical Therapy in Patients Hospitalized for Heart Failure With Reduced Ejection Fraction—Stephen J. Greene, MD, Gregg C. Fonarow, MD, and Javed Butler, MD, MPH, MBAHospitalists can save lives by optimizing guideline-directed heart failure medications for their patients with heart failure with reduced ejection fraction.Highlights of Recent Articles From Annals of Internal MedicineRisk for Recurrent Venous Thromboembolism and Bleeding With Apixaban Compared With Rivaroxaban: An Analysis of Real-World DataAnn Intern Med. 2022;175:20-28. Published 7 December 2021. doi:10.7326/M21-0717This retrospective, new-user cohort study used a U.S. commercial health insurance database to compare 18 618 new users of apixaban with 18 618 new users of rivaroxaban for treatment of venous thromboembolism (VTE). After propensity score matching, patients prescribed apixaban were found to have lower rates of recurrent VTE (hazard ratio, 0.77 [95% CI, 0.69 to 0.87]) and lower rates of intracranial or gastrointestinal bleeding (hazard ratio, 0.60 [CI, 0.53 to 0.69]) in a median of 102 days of follow-up.Key points for hospitalists include:These data suggest that, in new users of direct oral anticoagulants for the treatment of VTE, apixaban may be more effective and safer than rivaroxaban.This study is limited by its use of billing data (potential misclassification of variables) and its observational design (unmeasured confounders).Randomized trials comparing these 2 medications for the treatment of VTE are underway.Performance of the European Society of Cardiology 0/1-Hour, 0/2-Hour, and 0/3-Hour Algorithms for Rapid Triage of Acute Myocardial Infarction: An International Collaborative Meta-analysisAnn Intern Med. 2022;175:101-113. Published 23 November 2021. doi:10.7326/M21-1499This meta-analysis identified 32 studies (20 cohorts) with 30 066 patients to evaluate the diagnostic accuracies of the European Society of Cardiology 0/1-hour, 0/2-hour, and 0/3-hour algorithms guiding the use of high-sensitivity cardiac troponins for triage of patients with suspected acute myocardial infarction (MI). The pooled sensitivities and negative predictive values for the 0/1-hour (99.1% and 99.8%) and 0/2-hour (98.6%, and 99.6%) protocols were both higher than the 0/3-hour protocol (93.7% and 98.7%). The sensitivities for the 0/3-hour algorithm were especially low in studies that did not use the recommended clinical criteria to stratify risk. Specificities were similar across the algorithms (94.0% to 96.1%).Key points for hospitalists include:In this analysis, the 0/1-hour and 0/2-hour algorithms performed better than the 0/3-hour algorithm. The authors conclude that the 0/3-hour algorithm should not be used without the clinical criteria recommended in the guidelines.This analysis is limited by the significant variability among the included studies. Editorialists conclude that the 0/1- and 0/2-hour algorithms are sensitive enough to rule out MI without additional testing and are specific enough to diagnose MI and allow appropriate investigations and therapy.The editorialists also remind us that, among the 1 in 4 patients who remain undifferentiated after serial troponin measurement (i.e., serial troponin concentrations do not lie in the rule-in or rule-out categories), the optimal approach to further risk stratification remains unknown.Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation: A Multicenter Prospective Cohort StudyAnn Intern Med. 2022;175:29-35. Published 23 November 2021. doi:10.7326/M21-2981This multicenter, prospective cohort study examined outcomes of patients (n = 266) with isolated subsegmental pulmonary embolism, and lower-extremity venous ultrasonography negative for VTE, who were not treated with anticoagulation. Patients with active cancer, prior VTE, or hypoxemia were excluded. Follow-up included repeated venous ultrasonography 1 week into the study period and serial interviews to screen for VTE symptoms. Recurrence of VTE was 3.1% over the 90-day follow-up (2.1% for single and 5.7% for multiple isolated pulmonary embolism). No patients had a fatal VTE event. Recruitment was stopped early on the basis of the predefined stopping rule.Key points for hospitalists include:These data suggest that isolated subsegmental pulmonary embolism is associated with a significant risk for recurrent VTE, and the authors conclude that the results support the use of anticoagulation in this population.This observational study did not have a treatment group to demonstrate the rate of recurrent VTE in patients who were treated with anticoagulation.The incidence of recurrent VTE was “higher than initially expected” by the authors and similar to recurrence rates among patients with proximal pulmonary emboli who were treated with anticoagulation, as seen in a prior meta-analysis.Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants: A Cohort StudyAnn Intern Med. 2022;175:65-73. Published 9 November 2021. doi:10.7326/M21-1687This prospective cohort study assessed delirium in 527 hospitalized medicine patients using an app-delivered, 2-step screening tool consisting of 2 “ultra-brief” questions (UB-2), followed by additional testing with the 3-Minute Diagnostic Assessment for the Confusion Assessment Method (3D-CAM) if the UB-2 screen result was positive. Questions were administered by physicians, nurses, and certified nursing assistants, and the results were compared with a reference standard delirium assessment. The UB-2 portion alone was 81.9% to 88.2% sensitive for a delirium diagnosis, regardless of who performed it, with specificities ranging from 63.7% to 69.6%. The 2-step protocol (combining the UB-2 with the 3D-CAM) exhibited sensitivities of 64.8% (nurses) and 62.7% (physicians) and specificities of 92.9% (nurses) and 91.2% (physicians). Overall sensitivity of the 2-step protocol for moderate to severe delirium was 78%. Results were consistent across all provider types. Training of providers was very brief, and screening took at most a few minutes.Key points for hospitalists include:This study shows that a brief delirium screening protocol can identify delirium in hospitalized patients (with modest sensitivity but higher specificity) using a reference standard delirium assessment as the gold standard.Nursing assistants (only UB-2) and nurses (full 2-step protocol) did as well as hospitalists, suggesting that this type of screening may be appropriately delegated to nonphysicians.Because the patient population was elderly, predominantly White, English speaking, and without psychiatric and substance misuse disorders, these results may not be generalizable to diverse hospitalized patient populations.The Latest Highlights From Journal ClubIn non-critically ill patients with COVID-19, therapeutic anticoagulation improved survival to discharge without organ supportAnn Intern Med. 2021;174:JC134. doi:10.7326/ACPJ202112210-134In critically ill patients with COVID-19, therapeutic anticoagulation did not increase organ support–free daysAnn Intern Med. 2021;174:JC135. doi:10.7326/ACPJ202112210-135This multicenter, multinational randomized controlled trial randomly assigned hospitalized patients with COVID-19 (without a preexisting indication for anticoagulation) to therapeutic anticoagulation with heparin or usual thromboprophylaxis. Outcomes differed depending on the patients' severity of illness. In non–critically ill patients, therapeutic anticoagulation resulted in a higher rate of survival to discharge without organ support. In critically ill patients, there was no clear benefit.WHO provides 2 conditional recommendations for casirivimab–imdevimab combination therapy in COVID-19Ann Intern Med. 7 December 2021 [Epub ahead of print]. doi:10.7326/J21-0009This living World Health Organization guideline suggests that casirivimab–imdevimab combination therapy should be reserved for patient with nonsevere COVID-19 who are at the highest risk for hospitalization and for patients with severe or critical COVID-19 who are seronegative.Patients with COVID-19 had increased risk for acute MI and ischemic stroke at 14 d vs. matched controlsAnn Intern Med. 2021;174:JC142. doi:10.7326/ACPJ202112210-142This cohort study compared 86 742 patients with COVID-19 (hospitalized or not) with 348 841 matched controls. With 14 days of follow-up, the patients with COVID-19 had increased risk for MI (adjusted odds ratio, 6.61 [95% CI, 3.56 to 12.20]) and ischemic stroke (adjusted odds ratio, 6.74 [CI, 3.71 to 12.20]).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 (M.M., M.L., D.H.W.)Disclosures:Authors have reported no disclosures of interest. Forms can be viewed at http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-3315.* The authors contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Clinical Pearls—Stopping, Starting, and Optimizing Guideline-Directed Medical Therapy in Patients Hospitalized for Heart Failure With Reduced Ejection Fraction Stephen J. Greene , Gregg C. Fonarow , and Javed Butler Metrics January 2022Volume 175, Issue 1Page: HO1 ePublished: 18 January 2022 Issue Published: January 2022 CopyrightCopyright © 2022 by American College of Physicians. All Rights Reserved.Loading ...