Thursday, October 23, 2014

Wednesday, October 22, 2014

Acute right heart failure

---occurs in a variety of critical illnesses. It is probably under recognized. When recognized specific treatment strategies may suggest themselves and result in improved hemodynamics. Free full text review here.

Tuesday, October 21, 2014

George Lundberg: the EMR is a mess

Still, after all these years.

Statins and diabetes

As Larry Husten at Cardiobrief points out, statin use has been associated with slight elevations in blood sugar leading to a diagnosis of diabetes in small numbers of patients. (This phenomenon, by the way, has been observed in other classes of drugs such as thiazides). The clinical importance has been unclear.

Here is a study that sheds more light on the controversy. The study focused on microvascular disease. This is appropriate since it is well known that statins protect against macrovascular disease in a wide apectrum of patients with and without diabetes. From the paper:

Methods
We identified all patients living in Denmark who were aged 40 years or older and were diagnosed with incident diabetes between Jan 1, 1996, and Dec 31, 2009. We obtained patients' data from the Danish Patient Registry and information on drug use from the Danish Registry of Medicinal Product Statistics. We randomly selected 15 679 individuals from the database who had used statins regularly until their diagnosis of diabetes (statin users) and matched them in a 1:3 ratio with 47 037 individuals who had never used statins before diagnosis (non-statin users). Our primary outcome was to compare the cumulative incidence of diabetic retinopathy, diabetic neuropathy, diabetic nephropathy, or gangrene of the foot in statin users versus non-statin users. We analysed data with Cox regression models, adjusted for covariates including sex, age at diabetes diagnosis, and method of diabetes diagnosis. To address potential biases between statin users and non-statin users, we made adjustments to our analysis with a propensity score and with other factors. Median follow-up was 2·7 years (range 0—13).

Findings
During 215 725 person-years of follow-up, 2866 patients developed diabetic retinopathy, 1406 developed diabetic neuropathy, 1248 developed diabetic nephropathy, and 2392 developed gangrene of the foot. Compared with non-statin users, statin users had a lower cumulative incidence of diabetic retinopathy (hazard ratio 0·60, 95% CI 0·54—0·66; p less than 0·0001), diabetic neuropathy (0·66, 0·57—0·75; p less than 0·0001), and gangrene of the foot (0·88, 0·80—0·97; p=0·010), but not diabetic nephropathy (0·97, 0·85—1·10; p=0·62). These results were similar after adjusting for the competing risk of death, after matching for a propensity score, after adjusting for visits to a family doctor, and by stratification on covariates. The corresponding multivariable adjusted hazard ratio for risk of diabetes in the total population was 1·17 (95% CI 1·14—1·21; p less than 0·0001).

Interpretation
Use of statins before diagnosis of incident diabetes was not associated with an increased risk of microvascular disease. Whether statins are protective against some forms of microvascular disease—a possibility raised by these data—will need to be addressed in other studies similar to ours, in mendelian randomisation studies, and preferably in randomised controlled trials.


Monday, October 20, 2014

Delirium in the elderly: pharmacologic management is a last resort

From a paper in American Family Physician via Hospital Medicine Virtual Journal Club:

Treatment of delirium should focus on identifying and managing the causative medical conditions, providing supportive care, preventing complications, and reinforcing preventive interventions. Pharmacologic interventions should be reserved for patients who are a threat to their own safety or the safety of others and those patients nearing death.

Sunday, October 19, 2014

Comparison of anticoagulation strategies for acute VTE

There are now multiple strategies available. They were compared in a recent systematic review and meta-analysis:


Objective To summarize and compare the efficacy and safety outcomes associated with 8 anticoagulation options (unfractionated heparin [UFH], low-molecular-weight heparin [LMWH], or fondaparinux in combination with vitamin K antagonists); LMWH with dabigatran or edoxaban; rivaroxaban; apixaban; and LMWH alone) for treatment of venous thromboembolism.
Data Sources A systematic literature search was conducted using MEDLINE, EMBASE, and the evidence-based medicine reviews from inception through February 28, 2014.
Study Selection Eligible studies were randomized trials reporting rates of recurrent venous thromboembolism and major bleeding in patients with acute venous thromboembolism. Of the 1197 studies identified, 45 trials including 44 989 patients were included in the analyses.
Data Extraction and Synthesis Two reviewers independently extracted trial-level data including number of patients, duration of follow-up, and outcomes. The data were pooled using network meta-analysis.
Main Outcomes and Measures The primary clinical and safety outcomes were recurrent venous thromboembolism and major bleeding, respectively.
Results Compared with the LMWH–vitamin K antagonist combination, a treatment strategy using the UFH–vitamin K antagonist combination was associated with an increased risk of recurrent venous thromboembolism (hazard ratio [HR], 1.42; 95% credible interval [CrI], 1.15-1.79). The proportion of patients experiencing recurrent venous thromboembolism during 3 months of treatment were 1.84% (95% CrI, 1.33%-2.51%) for the UFH–vitamin K antagonist combination and 1.30% (95% CrI, 1.02%-1.62%) for the LMWH–vitamin K antagonist combination. Rivaroxaban (HR, 0.55; 95% CrI, 0.35-0.89) and apixaban (HR, 0.31; 95% CrI, 0.15-0.62) were associated with a lower risk of bleeding than was the LMWH–vitamin K antagonist combination, with a lower proportion of patients experiencing a major bleeding event during 3 months of anticoagulation: 0.49% (95% CrI, 0.29%-0.85%) for rivaroxaban, 0.28% (95% CrI, 0.14%-0.50%) for apixaban, and 0.89% (95% CrI, 0.66%-1.16%) for the LMWH–vitamin K antagonist combination.
Conclusions and Relevance Using meta-analytic pooling, there were no statistically significant differences for efficacy and safety associated with most treatment strategies used to treat acute venous thromboembolism compared with the LMWH–vitamin K antagonist combination. However, findings suggest that the UFH–vitamin K antagonist combination is associated with the least effective strategy and that rivaroxaban and apixaban may be associated with the lowest risk for bleeding.

Saturday, October 18, 2014

Cocaine related Aortic Dissection

From the International Registry of Acute Aortic Dissection:

Methods
Our study analyzed 3584 patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2012. We divided the population on the basis of documented cocaine use (C+) versus noncocaine use (C-) and further stratified the cohorts into type A (33 C+/2332, 1.4%) and type B (30 C+/1252, 2.4%) dissection.

Results
C+ patients presented at a younger age and were more likely to be male and black. Type B dissections were more common among C+ patients than in C- patients. Cocaine-related acute aortic dissection was reported more often at US sites than at European sites (86.4%, 51/63 vs 13.6%, 8/63; P less than .001). Tobacco use was more prevalent in the C+ cohort. No differences were seen in history of hypertension, known atherosclerosis, or time from symptom onset to presentation. Type B C+ patients were more likely to be hypertensive at presentation. C+ patients had significantly smaller ascending aortic diameters at presentation. Acute renal failure was more common in type A C+ patients; however, mortality was significantly lower in type A C+ patients.

Conclusions
Cocaine use is implicated in 1.8% of patients with acute aortic dissection. The typical patient is relatively young and has the additional risk factors of hypertension and tobacco use. In-hospital mortality for those with cocaine-related type A dissection is lower than for those with noncocaine-related dissection, likely due to the younger age at presentation.