Annals for Hospitalists - October 2021
Authors: Megan Mack, Matthew Luzum, David H. Wesorick
Journal: Annals of Internal Medicine (2021)

Web ExclusivesOctober 2021Annals for Hospitalists - October 2021FREEMegan Mack, MD*, Matthew Luzum, MD* and 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 and 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/AWHO202110190 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesChallenging the Myths of the Against Medical Advice Discharge—David Alfandre, MD, MSPHPatients sometimes request to be discharged from the hospital before their hospitalists would advise it. In this article, the author discusses the best approach to these situations.Highlights of Recent Articles From Annals of Internal MedicineLong-Term Risk for Major Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous Thromboembolism: A Systematic Review and Meta-analysisAnn Intern Med. 2021;174:1420-1429. Published 14 September 2021. doi:10.7326/M21-1094The MAJESTIC (MAJor blEeding riSk during exTended antICoagulation) collaborators conducted a systematic review and meta-analysis to determine the risk for major bleeding with anticoagulation for up to 5 years after the occurrence of a first unprovoked venous thromboembolism. Included were 17 202 patients from 27 randomized controlled trials and prospective cohort studies who had completed at least 3 months of initial anticoagulation with either a vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC) and continued anticoagulation for a minimum of 6 months beyond the initial anticoagulation period. Incidence of major bleeding events was 1.74 events per 100 person-years in patients receiving VKAs and 1.12 events per 100 person-years in those receiving DOACs. Cumulative incidence of major bleeding at 5 years with VKAs was 6.3%; there were insufficient data for cumulative incidence for DOACs beyond 1 year of extended anticoagulation. The case-fatality rate of major bleeding was 8.3% with VKAs and 9.7% with DOACs. Subgroup analysis found statistically significant increases in major bleeding events among patients with impaired renal function, age older than 65 years, concomitant antiplatelet use, previous history of bleeding, and lower hemoglobin levels for both VKAs and DOACs.Key points for hospitalists include:These data demonstrate that patients with an unprovoked VTE event who are treated with extended anticoagulation (beyond an initial 3 to 6 months) have a considerable incidence of major bleeding and death.These data may allow clinicians to make more evidence-based decisions about which patients are likely to benefit from extended anticoagulation treatment.This study lacked sufficient data to compare different dosing strategies for DOACs (that is, reduced dose vs. standard dose), and extended treatment for DOACs in the included studies was limited to 1 year.Midodrine for the Prevention of Vasovagal Syncope: A Randomized Clinical TrialAnn Intern Med. 2021;174:1349-1356. Published 3 August 2021. doi:10.7326/M20-5415This randomized, double-blind, placebo-controlled trial randomly assigned 133 young (median age, 32 years), healthy patients with the diagnosis of vasovagal syncope, with a high syncope burden (median, 6 syncopal episodes in the prior year), to either dose-titrated midodrine or placebo. Patients receiving midodrine were more likely to be free of syncopal episodes in the 1-year follow-up period (55% vs. 25%; number needed to treat to prevent 1 patient from having syncope was 5.3). Time to first syncope was also longer in the midodrine group.Key points for hospitalists include:These results show that in young, healthy patients with frequent vasovagal syncope, midodrine modestly increases the proportion of patients that remain syncope free for a year of follow-up.Recurrent syncope was common, even in patients receiving midodrine, and those patients that did have recurrences on midodrine exhibited a syncope frequency that was similar to those receiving placebo.An editorialist notes that midodrine can be added to the list of interventions that seem to help a subgroup of patients with vasovagal syncope (including counterpressure maneuvers, fludrocortisone, and cardiac pacing). He suggests that further advancement in the field will depend on our ability to match a patient's treatment with the precise mechanism of their syncope.The Latest Highlights From Journal ClubIs pharmacologic cardioversion effective for converting atrial flutter in the emergency department?In acute atrial flutter, adding pharmacologic before electrical cardioversion did not increase conversion to sinus rhythmAnn Intern Med. 2021;174:JC105. doi:10.7326/ACPJ202109210-105In this randomized controlled trial, 76 patients with atrial flutter were randomly assigned to either electrical cardioversion or to an infusion of procainamide, followed by electrical cardioversion, if needed. The combination did not significantly increase successful cardioversion, but the addition of the procainamide did increase the rates of adverse reactions.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 - Challenging the Myths of the Against Medical Advice Discharge David Alfandre Metrics October 2021Volume 174, Issue 10Page: HO10 ePublished: 19 October 2021 Issue Published: October 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.Loading ...