Annals for Hospitalists - 18 December 2018
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2018)

Web Exclusives18 December 2018Annals for Hospitalists - 18 December 2018FREEDavid 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/AFHO201812180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesNonexpert leadership: Can Hospitalists Turn the Tide of Aggressive End-of-Life Hospital Care?—Nauzley Christy Abedini, MDThe tendency to provide aggressive care to patients at the end life is deeply ingrained in our health care system. In this commentary, the author describes a patient she cared for and how hospitalists may be uniquely positioned to balance this practice.Highlights of Recent Articles from Annals of Internal MedicineUse of High-Sensitivity Cardiac Troponin for the Exclusion of Inducible Myocardial Ischemia: A Cohort StudyAnn Intern Med. 2018;169:751-760. Published 4 December 2018. doi: 10.7326/M18-0670This observational study examined patients (n = 589 in the derivation cohort, n = 118 in the validation cohort) with known, stable coronary artery disease (CAD) and evaluated the relationship between high-sensitivity cardiac troponin I (hs-cTnI) levels and the results of myocardial perfusion imaging (MPI). The study showed that patients with hs-cTnI levels below 2.5 pg/mL only rarely had significant inducible ischemia on MPI (negative predictive value [NPV] 97% [95% CI, 92% to 99%] in the derivation cohort; NPV 94% [CI 79% to 99% in the validation cohort]). In addition, patients with hs-cTnI < 2.5 pg/mL experienced no adverse events over a 3-year follow-up period, compared with a 7% rate of events (cardiovascular death or myocardial infarction) in patients with higher levels of hs-cTnI.Key points for hospitalists include:This study examines a new way of using hs-cTnI testing in patients with known, stable CAD. It showed that hs-cTnI testing identified a population of patients with a low likelihood of inducible ischemia on MPI as well as a low risk for adverse cardiac events over 3 years.Although hs-cTnI levels below the 2.5 pg/mL cutoff had a high NPV, hs-cTnI levels above this cutoff exhibited poor positive predictive value (17% [CI 14% to 21%]), suggesting that this approach is best used to identify a subgroup of low-risk patients.An editorialist noted that high-sensitivity troponin testing may be more useful than stress testing to predict the course of stable CAD but that the results need to be replicated and refined in larger studies. Interventions for Preventing Thromboembolic Events in Patients With Atrial Fibrillation: A Systematic ReviewAnn Intern Med. 2018;169:774-787. Published 4 December 2018. doi: 10.7326/M18-1523This systematic review synthesizes data from 220 articles comparing treatments to prevent stroke in patients with nonvalvular atrial fibrillation (AF). Most of the studies were observational, and most examined warfarin and the direct oral anticoagulants (DOACs). There were no randomized controlled trials directly comparing factor Xa inhibitors with each other or with dabigatran.Key points for hospitalists include:The review concludes that for preventing stroke or systemic embolism, dabigatran and apixaban are superior to warfarin and rivaroxiban and edoxaban are similar to warfarin.The review concludes that for terms of major bleeding rates, apixaban and edoxaban are superior to warfarin and rivaroxaban and dabigatran are similar to warfarin.The treatment effects of DOACs seem to be consistent across various patient subgroups, including those with a history of stroke, patients receiving concomitant aspirin therapy, patients with heart failure, and those with paroxysmal (vs. persistent) AF.The authors note the substantial limitations of indirect comparisons of medications and use of observational data to compare medication effects. They call for head-to-head randomized trials to compare the DOACs.Diagnosis of Pulmonary Embolism During Pregnancy: A Multicenter Prospective Management Outcome StudyAnn Intern Med. 2018;169:766-773. Published 4 December 2018. doi:10.7326/M18-1670This prospective diagnostic study of 395 pregnant women examined the outcomes of a defined diagnostic approach to suspected pulmonary embolism (PE). The approach was similar to that commonly recommended for nonpregnant patients and included a pretest probability calculation (revised Geneva score); D-dimer testing for low- or intermediate-risk patients; and an imaging cascade that included lower limb venous Doppler ultrasonography, computed tomography (CT) scanning, and VQ scanning (in cases of inconclusive CT results). When PE was ruled out with this approach, the symptomatic venous thrombosis rate at 3-month follow-up was 0% (CI, 0.0% to 1.0%).Key points for hospitalists include:The diagnostic approach seems to be safe and effective in this patient population.The use of D-dimer testing in this population appears to be beneficial. The contribution of lower limb venous Doppler testing is small but would be expected to eliminate the need for radiation exposure for a few women (positive for DVT in 7 of 395 women in which it was performed). The rate of inconclusive CT results was less than previously reported. Editorialists note that the primary weakness of this approach is that it uses a pretest probability rule that has not been validated in pregnant women and suggest that it may be an important area for future research. Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic TrialAnn Intern Med. 2018;169:855-865. Published 18 December 2018. doi:10.7326/M18-1206This study examined the effect of a computer-based clinical decision support system that helped identify low-risk patients with pulmonary embolism (PE) who could be safely discharged home from the emergency department (or after a < 24-hour observation period). The study was a pre–post design that compared a convenience sample of 10 hospitals (n = 881) with 11 other hospitals that served as concurrent controls (n = 822). The intervention featured an automatically calculated PE Severity Index score that identified low-risk patients, accompanied by a list of relative contraindications to outpatient care. Provision of this information to providers resulted in an increase in the number of patients discharged home (17.4% before and 28% after the intervention). The control hospitals had discharge rates of 15.1% and 14.5% during the corresponding periods.Key points for hospitalists include:The main finding of this study is that a well-implemented computer decision-support system can change clinical behavior in ways that benefit patients and reduce cost. Editorialists suggest that this intervention was successful because it simplified the otherwise complex process of selecting patients with PE that were appropriate for outpatient management. Patients that were discharged home did not have an increase in adverse events compared with their hospitalized counterparts, strengthening the evidence that low-risk patients can be safely managed without hospitalization.The Latest Highlights From ACP Journal ClubDoes reduced-dose extended DOAC therapy reduce risk for VTE as much as regular-dose extended treatment?Review: In VTE, reduced- and full-dose extended DOAC therapies do not differ and are better than no extended therapyAnn Intern Med. 2018;169:JC52. doi: 10.7326/ACPJC-2018-169-10-052This review examines 2 randomized controlled trials (n = 5847) that compared a regular-dose extension of anticoagulation to a reduced-dose extension in patients being treated for venous thromboembolism (VTE). After 3 to 12 months of DOAC therapy (apixaban in one study, rivaroxaban in the other), patients were randomly assigned to continue the full DOAC treatment dose, reduce the dose by half, or discontinue anticoagulation altogether for the next 12 months. Both the full dose and the reduced dose prevented recurrent VTE (1.4% and 1.2% recurrent VTE rates compared with 6.3% for no anticoagulation). However, reduced-dose extended anticoagulation had significantly lower rates of bleeding. This suggests that future DOAC VTE treatment strategies may favor longer treatment courses with lower doses.In patients with coronary artery disease, how does PCI compare to CABG for risk of stroke?Review: In coronary artery disease, PCI reduces 30-day and 5-year risk for stroke compared with CABGAnn Intern Med. 2018;169:JC55. doi: 10.7326/ACPJC-2018-169-10-055This review examined 11 randomized controlled trials (n = 11 518) of patients with left main or multivessel CAD who were randomly assigned to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The review confirms that the risk for stroke with CABG is significantly higher than with PCI but is offset by a reduced risk for myocardial infarction and revascularization in patients having CABG.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 - Nonexpert Leadership—Can Hospitalists Turn the Tide of Aggressive End-of-Life Hospital Care? Nauzley Christy Abedini Metrics 18 December 2018Volume 169, Issue 12Page: HO12KeywordsApixabanComputed axial tomographyHospitalistsMyocardial infarctionMyocardial perfusion imagingNegative predictive valuePercutaneous coronary interventionPulmonary embolismStable coronary artery diseaseStroke ePublished: 18 December 2018 Issue Published: 18 December 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.Loading ...