Annals for Educators - July 2021
Authors: Christine Laine
Journal: Annals of Internal Medicine (2021)

Web ExclusivesJuly 2021Annals for Educators - July 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202107200 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsEffectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation. A Population-Based Cohort StudyDirect oral anticoagulants (DOACs) are increasingly used in place of warfarin, but evidence on their effectiveness and safety in patients with valvular atrial fibrillation is limited. This study examined the effectiveness and safety of DOACs compared with warfarin in patients with valvular atrial fibrillation.Use this article to:Start your educational session with a MKSAP question. We provide one below!Ask your learners whether there are important differences in the risk for various clinical outcomes in patients with valvular versus nonvalvular atrial fibrillation.Invite a pharmacist to join the session to review the DOACs that are most commonly prescribed in your health system.Discuss the limitations of the cohort study design in answering the question this study aimed to answer.What factors should clinicians consider when choosing anticoagulation for a patient with valvular atrial fibrillation?Miners' Nystagmus Following Visual Deprivation: A Case ReportMiners' nystagmus was first recognized in the 1870s in coal miners, in whom it developed after they spent years working underground. This contemporary case describes the development of the syndrome in a patient who avoided light because of chronic headaches.Use this article to:Demonstrate the physical examination for nystagmus, and have your learners practice it on each other.Go to the article and watch the video of the patient's eye examination. Review other occupation-related health conditions in coal miners. Are they seen in other settings during contemporary times?Toward Understanding COVID-19 Recovery: National Institutes of Health Workshop on Postacute COVID-19Heterogeneous disease manifestations are now recognized among some persons after initial recovery from SARS-CoV-2 infection. The National Institute of Allergy and Infectious Diseases convened a virtual workshop to summarize existing knowledge and to identify key knowledge gaps regarding this condition.Use this article to:Ask your learners about the follow-up that is generally recommended for patients at the time of discharge after hospitalization for COVID-19 at your institution.If your institution has a clinical program devoted to care of patients after COVID-19, invite a clinician from that program to discuss the symptoms patients are experiencing and the program's strategies for evaluation and management.After reading the article, watch the video of a June 2021 Annals/ACP program on evaluation and management of patients with persistent symptoms after acute infection. Is Comprehensive Geriatric Assessment Admission Avoidance Hospital at Home an Alternative to Hospital Admission for Older Persons? A Randomized TrialHospital at Home for Older Patients With Underlying ComorbidityAvoiding hospital admission is often a priority for frail older persons, but the safety and clinical effectiveness of hospital-level care in the home are uncertain. This randomized trial, which compared outcomes with hospital at home versus hospitalization among older patients requiring hospital-level care, contributes to a growing body of research on hospital-level care at home. The accompanying editorial highlights how this care model can work in older patients with substantial comorbidity.Use this article and editorial to:Discuss whether your own institution or others in your community offer “hospital-at-home” care.Ask your learners to briefly describe the patients they admitted to the hospital over the past week and whether each patient might have been eligible for the trial reported in this article.Ask your learners to reflect on patients they have cared for during a hospitalization who might have had better outcomes had they been cared for in a hospital-at-home program.Clinical GuidelinesAppropriate Use of Point-of-Care Ultrasonography in Patients With Acute Dyspnea in Emergency Department or Inpatient Settings: A Clinical Guideline From the American College of PhysiciansPoint-of-Care Ultrasonography in Patients With Acute Dyspnea: An Evidence Report for a Clinical Practice Guideline by the American College of PhysiciansThis guideline provides recommendations on the use of point-of-care ultrasonography (POCUS) in emergency department or inpatient settings for diagnosis of acute dyspnea suspected to be due to congestive heart failure, pleural effusion, pneumonia, pneumothorax, or pulmonary embolism. The accompanying systematic review evaluated the effectiveness, test accuracy, and harms of POCUS in patients with acute dyspnea.Use these articles to:Discuss whether, in which settings, and for what purposes POCUS is used at your institution.Review the recommendations and discuss the benefits and harms of using POCUS in the evaluation of patients with acute dyspnea.Ask a radiologist or another clinician with expertise in POCUS to join your session and demonstrate how to perform POCUS to evaluate a patient with acute dyspnea.MenopauseThis review focuses on the diagnosis and management of menopause, highlighting both hormonal and nonhormonal treatment options. In particular, the review focuses on newer data about the risks and benefits of hormone therapy to help clinicians better counsel their patients about decision making with regard to understanding and treating menopause symptoms.Use this article to:Review how to determine whether a patient is experiencing menopause. Are there laboratory tests that are helpful?Review nonhormonal therapies that have documented evidence of effectiveness in the management of menopause-related symptoms.What are the documented health risks associated with hormone therapy when used to manage symptoms of menopause?Ask your learners to describe the agents, dose, and duration of hormone therapy that would be appropriate if a patient wanted to try hormone therapy after shared decision making.Public HealthSpatial Inequities in COVID-19 Testing, Positivity, Confirmed Cases, and Mortality in 3 U.S. Cities. An Ecological StudyInjustice in Health: Now Is the Time to Change the StoryThis study used data from Philadelphia, Chicago, and New York City and the Centers for Disease Control and Prevention Social Vulnerability Index to explore inequities in COVID-19 testing, positivity, confirmed cases, and mortality during the first 6 months of the pandemic. The accompanying editorial discusses how the findings reveal a public health catastrophe in the making.Use this article and editorial to:Ask your learners whether they have observed inequities in COVID-19–related care and outcomes in your health system and surrounding communities.Brainstorm about potential strategies and programs that might alleviate observed inequities.Compile a list of social determinants of health that must be considered when caring for patients. This ACP position paper and this U.S. Preventive Services Task Force article provide useful background and context. ACP AnnouncementCheck Out ACP's Online Resident Well-being Curriculum!ACP's online Resident Well-being Curriculum connects residents with evidence-based strategies to foster well-being and mitigate burnout. Ideal for a residency program, the curriculum is designed to be used in a flipped classroom model. Residents review online material before a live small-group discussion. The curriculum is aligned with the new ACGME requirements for resident training in well-being. The curriculum consists of 3 online, multimedia modules that can be taught individually or as a complete program and offers individual and organizational strategies.• Well-being and Burnout in Residency: Study burnout, its effects on physicians and patients, and the unique challenges faced by residents.• Individual and Organizational Strategies: Explore organizational well-being strategies, explore the existing ACGME well-being requirements and leave policies, and learn how to build a personal well-being plan.• Promoting Collaborative Learning Environments for Well-being: Learn the value of collaborative learning environments and positive social interaction, as well as how to recognize harmful signs of burnout in oneself or peers and how to seek help.The modules are free to ACP members. Learn more here. MKSAP 18 QuestionA 53-year-old woman is evaluated for recent onset of palpitations. Until the onset of palpitations, the patient was asymptomatic. She has hypertension treated with chlorthalidone and type 2 diabetes mellitus treated with metformin.On physical examination, pulse rate is 87/min and irregular; other vital signs are normal. Cardiovascular examination reveals an irregular rhythm with variable intensity of S1; an opening snap and a grade 2/6 diastolic rumbling murmur are heard at the cardiac apex.An electrocardiogram shows atrial fibrillation but is otherwise unremarkable. Transthoracic echocardiographic findings are consistent with rheumatic mitral valve stenosis of moderate severity.Which of the following is the most appropriate management to prevent thromboembolism in this patient?A. Begin aspirinB. Begin dabigatranC. Begin warfarinD. Calculate the CHA2DS2-VASc scoreCorrect AnswerC. Begin warfarinEducational ObjectivePrevent thromboembolism in a patient with valvular atrial fibrillation.CritiqueThe most appropriate management to prevent thromboembolism in this patient with valvular atrial fibrillation is warfarin. Valvular atrial fibrillation refers to atrial fibrillation in the setting of moderate to severe mitral stenosis or in the presence of a mechanical heart valve. Valvular atrial fibrillation is considered an indication for long-term anticoagulation with warfarin regardless of the CHA2DS2-VASc score. Non–vitamin K antagonist oral anticoagulants (NOACs) are not approved for use in valvular atrial fibrillation. However, patients with atrial fibrillation and other valvular lesions (mild mitral stenosis, aortic valve disease, mitral regurgitation, and tricuspid regurgitation) are eligible for NOAC therapy.Due to lack of evidence, guidelines do not support the use of aspirin as monotherapy for the prevention of thromboembolic events in patients with atrial fibrillation, even in very low-risk patients. Patients with valvular atrial fibrillation are at high risk for thromboembolism, and aspirin monotherapy is inadequate to prevent thromboembolism.Current guidelines recommend the use of the CHA2DS2-VASc score in patients with nonvalvular atrial fibrillation. Men with nonvalvular atrial fibrillation who have a CHA2DS2-VASc score of 2 or higher and women with nonvalvular atrial fibrillation who have a score of 3 or higher should be treated with anticoagulation to prevent stroke. In NOAC-eligible patients, a NOAC is preferred to warfarin. In patients with moderate to severe mitral stenosis or a mechanical heart valve, warfarin is indicated regardless of the CHA2DS2-VASc score.NOACs, such as dabigatran, edoxaban, apixaban, and rivaroxaban, are not approved for use in valvular atrial fibrillation. Additionally, the RE-ALIGN trial of dabigatran versus warfarin in patients with mechanical heart valves was stopped because of an unacceptable rate of bleeding and thromboembolic events in the dabigatran group. Although no data regarding the other NOACs are available, the presence of a mechanical heart valve is considered a contraindication to all NOACs.Key PointValvular atrial fibrillation is an indication for long-term anticoagulation with warfarin regardless of the CHA2DS2-VASc score.BibliographyJanuary CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. 2019:CIR0000000000000665. doi:10.1161/CIR.0000000000000665Do 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 July 2021Volume 174, Issue 7Page: ED7KeywordsAtrial fibrillationCOVID-19DyspneaHormonal therapyHormonesMenopauseSafetyThromboembolismTreatment guidelinesUltrasound imaging ePublished: 20 July 2021 Issue Published: July 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...