Sunday, May 03, 2015

Proton pump inhibitors coadministered with dual antiplatelet therapy: the controversy continues



Thirty-five studies were eligible. Five (4 randomized controlled trials and 1 observational) assessed the effect of omeprazole when added to DAPT; the other 30 (observational) assessed the effect of PPIs as a class when compared with no PPIs. Random-effects meta-analyses of the studies assessing PPIs as a class consistently reported higher event rates in patients receiving PPIs for various clinical outcomes at 1 year (composite ischemic end points, all-cause mortality, nonfatal MI, stroke, revascularization, and stent thrombosis). However, the results from randomized controlled trials evaluating omeprazole compared with placebo showed no difference in ischemic outcomes, despite a reduction in upper gastrointestinal bleeding with omeprazole.

Conclusions—Large, well-conducted observational studies of PPIs and randomized controlled trials of omeprazole seem to provide conflicting results for the effect of PPIs on cardiovascular outcomes when coadministered with DAPT. Prospective trials that directly compare pharmacodynamic parameters and clinical events among specific PPI agents in patients with unstable angina/non–ST-segment–elevation myocardial infarction treated with DAPT are warranted.

Saturday, May 02, 2015

Aspirin lowers mortality in patients with community acquired pneumonia



Methods and Results Consecutive patients admitted to the University‐Hospital Policlinico Umberto I (Rome, Italy) with community‐onset pneumonia were recruited and prospectively followed up until discharge or death...

One thousand and five patients (age, 74.7±15.1 years) were included in the study: 390 were receiving aspirin (100 mg/day) at the time of hospitalization, whereas 615 patients were aspirin free. During the follow‐up, 16.2% of patients died; among these, 19 (4.9%) were aspirin users and 144 (23.4%; P less than 0.001) were aspirin nonusers. Overall, nonfatal CVEs occurred in 7% of patients, 8.3% in nonaspirin users, and 4.9% in aspirin users (odds ratio, 1.77; 95% confidence interval, 1.03 to 3.04; P=0.040). The Cox regression analysis showed that pneumonia severity index (PSI), severe sepsis, pleural effusion, and PaO2/FiO2 ratio less than 300 negatively influenced survival, whereas aspirin therapy was associated with improved survival. Compared to patients receiving aspirin, the propensity score adjusted analysis confirmed that patients not taking aspirin had a hazard ratio of 2.07 (1.08 to 3.98; P=0.029) for total mortality.

Conclusions This study shows that chronic aspirin use is associated with lower mortality rate within 30 days after hospital admission in a large cohort of patients with pneumonia.

This is astounding and far more robust than any of today's core measures or care pathway components. This is yet another reason core measures are ineffective: they are hopelessly out of date. Remember, this finding is not new. Based on an older study I suggested, almost two years ago, that aspirin administration be part of the pneumonia order set.

Friday, May 01, 2015

Are face-to-face handoffs really necessary?


This question was examined in a recent study of hospitalized patients:

OBJECTIVE

Examine the relationship between face-to-face handoffs and the rate of patient outcomes, including adverse events.

DESIGN

Retrospective cohort.

SETTING

A 1157-bed academic tertiary referral hospital.

PATIENTS

There were 805 adult patients admitted to general internal medicine services.

INTERVENTION

Retrospective comparison of clinical outcomes, including the rate of adverse events, of patients whose care was transitioned with and without face-to-face handoffs.
MEASUREMENTS

Rapid response team calls, code team calls, transfers to a higher level of care, death in hospital, 30-day readmission rate, length of stay, and adverse events (as identified using the Global Trigger Tool).

RESULTS

There was no significant difference with respect to the frequency of rapid response team calls, code team calls, transfers to a higher level of care, deaths in hospital, length of stay, 30-day readmission rate, or adverse events between patients whose care was transitioned with or without a face-to-face handoff.

From comments on this study in ACPHospitalist Weekly:

However, they speculated that the lack of effect with face-to-face handoffs could suggest that clinicians were more vigilant in gathering data when they didn't receive a face-to-face handoff, spending more time reviewing the medical record, speaking with the patients, and communicating with other clinicians.

The results suggest that, as long as key information is communicated by other means (such as electronic tools, email, or phone), a face-to-face handoff is "not vital to ensure a safe care transition," the authors wrote. Future investigations should look for other strategies or qualities that affect the safety of handoffs, they suggested.


Cost comparisons in ACS for PCI and non-PCI capable hospitals



Conclusions—Despite higher PCI and coronary artery bypass graft rates for Medicare patients initially presenting to PCI hospitals, PCI hospitals were only $627 costlier than non-PCI hospitals for the treatment of patients with acute myocardial infarction in 2008.

Thursday, April 30, 2015

Outpatient treatment of PE: what does the evidence tell us?



SEARCH METHODS:

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched October 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 9). The TSC also searched clinical trials databases. The review authors searched LILACS (last searched November 2014).

SELECTION CRITERIA:

Randomized controlled trials of outpatient versus inpatient treatment in people diagnosed with acute PE...

MAIN RESULTS:

We included one study, involving 339 participants. We ranked the quality of the evidence as very low due to not blinding the outcome assessors, the small number of events with imprecision in the confidential interval (CI), the small sample size and it was not possible to verify publication bias. For all outcomes, the CIs were wide and included clinically significant treatment effects in both directions: short-term mortality (30 days) (RR 0.33, 95% CI 0.01 to 7.98, P = 0.49), long-term mortality (90 days) (RR 0.98, 95% CI 0.06 to 15.58, P = 0.99), major bleeding at 14 days (RR 4.91, 95% CI 0.24 to 101.57, P = 0.30) and 90 days (RR 6.88, 95% CI 0.36 to 134.14, P = 0.20), recurrent PE within 90 days (RR 2.95, 95% CI 0.12 to 71.85, P = 0.51) and participant satisfaction (RR 0.97, 95% CI 0.92 to 1.03, P = 0.30). PE-related mortality, minor bleeding, and adverse course such as hemodynamic instability and compliance were not assessed by the single included study.

AUTHORS' CONCLUSIONS:

Current very low quality evidence from one published randomized controlled trial did not provide sufficient evidence to assess the efficacy and safety of outpatient versus inpatient treatment for acute PE in overall mortality, bleeding and recurrence of PE adequately. Further well-conducted research is required before informed practice decisions can be made.

Now that target specific oral anticoagulants are approved for PE treatment this becomes an important question. If good quality RTC evidence is unavailable we do have other types of evidence that address the problem, specifically evidence showing that, using biomarkers, echocardiography and clinical criteria we can predict patients whose sort term risk is very low. Is that type of evidence enough? Do we even need RCT evidence?



Wednesday, April 29, 2015

Saddle pulmonary embolism and knee jerk alarm


Here's an interesting paper linked at Hospital Medicine Virtual Journal Club. From the abstract:

Saddle pulmonary embolism (PE) is defined as the presence of a visible thromboembolus that straddles the bifurcation of the main pulmonary artery. It occurs in about 2-5% of all PE cases [1]. Visualization of saddle PE on a Computed Tomography (CT) scan causes alarm among physicians due to the possibility of a large clot burden and impending hemodynamic collapse. However, recent studies have challenged this reflexive assumption, along with the assumption that clot burden predicts outcomes [2].

Not that saddle PE isn't serious, but all too often the appearance of a “saddle” trumps further thinking about parameters that mean more such as the shock index, biomarkers and echocardiographic assessment of RV function.

Tuesday, April 28, 2015

New oral anticoagulants for heparin induced thrombocytopenia (HIT)

Low level evidence suggests they may provide an alternative:
MATERIALS AND METHODS:

We retrospectively identified 22 patients with HIT who were treated by our group with a combination of NOAC and a short course of argatroban. These patients were evaluated in a prospective fashion for development of outcomes at a mean follow up of 19±3months.

RESULTS:

There were a total of 5 deep and 2 superficial vein thromboses diagnosed at index hospitalization. No patient developed arterial thrombosis. All patients tolerated NOAC and their platelet count normalized before discharge. At 19months of follow-up, 6 patients had died of non-thrombotic causes. There was no bleeding, limb loss or recurrent venous thromboembolism in any patient.

CONCLUSIONS:

In patients with HIT, a short course of parenteral treatment with argatroban followed by administration of a NOAC is highly safe and effective in prevention of thrombosis and normalization of platelet count. Development of HIT however, portends a poor prognosis independent of vascular thrombosis.

Via Hospital Medicine Virtual Journal Club.