papers from 2015 that changed my practice
TRANSCRIPT
![Page 1: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/1.jpg)
Papers from 2015
That Changed My Practice
Jon Sweet, MD, FACP
Carilion Clinic &
Virginia Tech Carilion School of Medicine
![Page 2: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/2.jpg)
Disclosures
• None
![Page 3: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/3.jpg)
Case: VTE
• 64 yo man admitted withan unprovoked pulmonary embolism, his first episode of VTE.No weight loss, cough, or GI complaints
• PMH: HTN and T2DM. No abnormal bleeding
• Meds: Lisinopril, amlodipine, metformin
• Occasional ETOH, non-smoker. Not very active.
• BP 142/80, HR 106, RR 20, afebrile
• You start rivaroxaban 15 mg PO BID
![Page 4: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/4.jpg)
How long should he be
anticoagulated?
A. 3 month
B. 6 months
C. 24 months
D. Indefinitely
![Page 5: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/5.jpg)
• Question: can normal D-dimer levels during and 1 month after cessation of anticoagulation predict a recurrent VTE rate low enough to justify cessation of anticoagulation?
• Prospective cohort study w/ blinded outcome assessment
• 410 adult with first VTE (PE or proximal DVT leg); 13 centers
• Anticoagulation stopped if D-dimer negative and not restarted if remained negative after 1 month
• Outcome: recurrent VTE (average follow-up 2.2 y)
![Page 6: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/6.jpg)
Results: Kearon, et al.
• 78% had 2 negative D-dimers and therefore stopped
anticoagulation
– 2 had recurrence before repeat test
• Recurrence rate for VTE per patient-year
Group % per Patient-Year 95% CI
Overall 6.7 4.8 to 9.0
Men 9.7 6.7 to 13.7
Women 5.4 2.5 to 10.2
Estrogen-
associated
0 0.0 to 3.0
![Page 7: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/7.jpg)
• Randomized, blinded, placebo-controlled trial of
additional 18 months VKA
• 374 adults, 18 centers
• Follow-up planned for 42 months; stopped after
18 by steering committee
• Primary outcome: symptomatic recurrent VTE
or major bleeding
• Patient follow-up: 97%JAMA 2015;314:31-40
![Page 8: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/8.jpg)
PADIS-PE
ACP Journal Club, 11/17/15
![Page 9: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/9.jpg)
![Page 10: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/10.jpg)
Is our patient low risk for
bleeding?• HAS-BLED
– 0 = 1% annual risk of bleeding
• ATRIA
– 0 = 0.76% annual risk of bleeding
![Page 11: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/11.jpg)
In addition to age-appropriate
cancer screenings should patient
undergo CT abdomen & pelvis
A. Yes
B. No
![Page 12: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/12.jpg)
• Question: does extensive testing increase
diagnosis of occult cancer or reduce mortality in
the ~10% of patients who will develop overt
cancer in the 1-2 years after unprovoked VTE
![Page 13: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/13.jpg)
SOME Trial
• 862 adults with first unprovoked VTE; 9 centers
• Age-appropriate screening alone versus with CT
abdo/pelvis
• Primary outcome: Dx of cancer after initial
negative screening
– Secondary: recurrent VTE, cancer mortality,
all-cause mortality
• Patient follow-up: 95%
• Results: No differences in any outcome
![Page 14: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/14.jpg)
Pearls
• Extended anticoagulation is recommended
in those at low risk of bleeding
• In the setting of a first unprovoked VTE,
screening CT abdomen & pelvis is not
helpful and possibly harmful (radiation,
incidental findings, expense)
![Page 15: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/15.jpg)
Case 2: CAP
• 68 yo man admitted with typical symptoms of PNA. No hx of same. No COPD or HIV risk factors.
• PMH: HTN, T2DM, GERD, hx of colon cancer (2007).
• 20 pack-years tobacco, none in 30 years
• Influenza, PPSV23 and PCV13 vaccines UTD
• Meds: lisinopril, metformin, glipizide, omeprazole
• BP 110/74, HR 106, RR 24, T 103.2 F
• Mild distress, findings of consolidation over right posterior middle lung zone. No wheezes, JVD or S3.
• WBC 19,000, BUN 28, Cr 1.2
![Page 16: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/16.jpg)
In addition to ceftriaxone and
azithromycin, you add?
A. Nothing
B. Nebulized albuterol and ipratropium every
4 hours while awake
C. Prednisone PO daily
D. Methylprednisolone IV every 6 hours
E. Vancomycin
![Page 17: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/17.jpg)
• 802 adults, mean age 74, 62% men
• 7 tertiary care hospitals
• Prednisone 50 mg QD x 7 days
• Primary outcome: clinical stability x 24 h
– T <37.8, HR <100, RR <24, SBP >90 (>100 if
Hx HTN), Sat >90% RA, baseline mental
status, oral intake
![Page 18: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/18.jpg)
![Page 19: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/19.jpg)
![Page 20: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/20.jpg)
![Page 21: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/21.jpg)
• 13 RCTs
• 2005 patients
• Variety of different steroids and regimens
compared to placebo
![Page 22: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/22.jpg)
Siemieniuk et al
All-cause
mortality
RR 0.67 95% CI, 0.45 to 1.01
Need for
mechanical
ventilation
RR 0.45 0.26 to 0.79
ARDS RR 0.24 0.10 to 0.56
Time to clinical
stability
-1.22 d -2.08 to -0.35
LOS -1.00 d -1.79 to -0.21
Hyperglycemia
requiring
treatment
RR 1.49 1.01 to 2.19
![Page 23: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/23.jpg)
Pearl
• Treatment of CAP with prednisone leads to
reduction in time to clinical stability,
decreased LOS, decreased duration of IV
ABX, decreased ARDS and need for
mechanical ventilation with an increase
in hyperglycemia requiring insulin
![Page 24: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/24.jpg)
Case 3: Stroke
• 72 yo R-handed woman evaluated2 hrs after the sudden onset ofexpressive aphasia and right armweakness
• PMH: HTN, osteoporosis
• Meds: HCTZ, amlodipine, alendronate, calcium, vitamin D
• BP 172/82, HR 78, RR 18, afebrile
• Dense expressive aphasia and 2/5 RUE weakness
• CBC, CMP, PT INR unremarkable
![Page 25: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/25.jpg)
What is the best approach to
this patient?
A. Aspirin
B. Aspirin plus clopidrogrel
C. Alteplase
D. Endovascular treatment
E. Alteplase followed by endovascular
treatment
![Page 26: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/26.jpg)
![Page 27: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/27.jpg)
Endovascular Management of
Acute Ischemic Stroke• Earlier trials with earlier-generation devices
(Merci, Penumbra) did not help
– 2013: MR RESCUE, IMS III, SYNTHESIS Expansion
• Newer-generation stent-retrievers are safer and
more effective
– Inclusion criteria differed slightly
– Intracranial ICA or proximal MCA
– Functionally independent before stroke
– Intervention feasible within 6 hours
– Most patients received TPA
![Page 28: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/28.jpg)
Modified Rankin ScaleScore Description
0 No symptoms
1 No significant disability; can do all duties & activities
2 Slightly disability; can’t do all previous activities but CAN handle affairs without assistance
3 Moderate disability; needs some help but can WALK WITHOUT ASSISTANCE
4 Moderately severe disability; needs help with ADLs; CAN’T WALK without assistance
5 Severe disability, bedridden, incontinent, constant nursing care
6 Dead
• mRS 0 – 2 = Functional Independence
![Page 29: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/29.jpg)
mRS 0 – 2 at 90 Days
Trial Stent-Retriever (%) Standard Care (%)
MR CLEAN 33 19
EXTEND-IA 71 40
ESCAPE 53 29
SWIFT PRIME 60 35
REVASCAT 44 28
• Mortality was lowered in only one trial
• AHA/ASA have updated their guidelines (Class I, level A
if eligible for at least 2 of the trials above)
• Challenge: delivering endovascular intervention in a
timely fashion (groin puncture <6 h)
![Page 30: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/30.jpg)
Pearl
• Mechanical thrombectomy following thrombolysis
improves functional outcomes at 90 days
compared to thrombolysis alone and is the
treatment of choice for suitable candidates with
severe strokes (NIHSS >6) and large vessel
occlusions (ICA or M1)
![Page 31: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/31.jpg)
• 42 yo nurse is your office c/o the sudden onset of palpitations 30 minutes ago, mild dyspnea and apprehension. This has happened before, but has always resolved within minutes without treatment
• PMH: hypothyroidism
• Meds: levothyroxine
• HR 200 (regular), BP 94/50, RR 20, afebrile
![Page 32: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/32.jpg)
The best initial approach would be?
A. Valsalva maneuver
B. Modified valsalva maneuver
C. Check D-dimer, TSH, electrolytes
D. Adenosine 6 mg IV x 1
E. Transfer to Emergency Department
![Page 33: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/33.jpg)
• Valsalva is effect only 5%-20% of time
• Adenosine is not well-tolerated
• Question: would a modified valsalva which
increases relaxation phase venous return and
vagal stimulation be more effective?
• 433 adults randomized (1:1), 10 U.K. EDs
– No Afib/Flutter
• Primary outcome: NSR at 1 minute
![Page 34: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/34.jpg)
Modified Valsalva Technique
• 15 s, 40 mm Hg semi-recumbent Valsalva
strain then immediate supine position
with passive leg raise (45° x 15 s)
– “Lying down with leg lift Valsalva”
– Or blow into 10 mL syringe enough to
move the plunger
• Repeat x 1 PRN
• For home: written instructions, 10 mL
syringe, website
![Page 35: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/35.jpg)
Modified Valsalva in SVT
Outcome Event Rates NNT (CI)
Modified Standard
Sinus rhythm
at 1 min
43 17 4 (3 to 7)
Adenosine in
ED
50 59 6 (4 to 12)
Any
antiarrhythmi
c
57 80 5 (3 to 8)
• No differences in time in ED, discharge to
home, or adverse effects
![Page 36: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/36.jpg)
Pearl
• A simple modification to the Valsalva
maneuver dramatically increases its
effectiveness in terminating SVT and
decreases the need for adenosine
![Page 37: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/37.jpg)
Case: HTN
• 42 yo man with resistanthypertension on HCTZ25 mg, lisinopril 40 mgand amlodipine 10 mgdaily
• No tobacco, drugs, NSAIDS, or pseudoephredrine. Occasional ETOH
• STOP-BANG score = 2 (HTN, male)
• BP 152/88, HR 70, BMI 26, Cr 1.2
![Page 38: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/38.jpg)
Which of the following is the
most appropriate?
A. Add clonidine
B. Add doxazosin
C. Add hydralazine
D. Add metoprolol
E. Add spironolactone
F. Change HCTZ to furosemide
![Page 39: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/39.jpg)
• Resistant HTN is common and treatment
approach is undefined
• Many patients might have sodium retention
or aldosteronism
• 335 adults (ages 18-79) with resistant HTN
• 14 sites in UK
![Page 40: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/40.jpg)
PATHWAY-2
• Double-blind, placebo-controlled, cross-
over trial in random 12 wk blocks
– Spironolactone 25 mg 50 mg
– Bisoprolol 5 mg 10 mg
– Doxazosin 4 mg 8 mg
– Placebo
– Dose doubled after 6 weeks
• Analysis by intention to treat
![Page 41: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/41.jpg)
Spironolactone is most effective
![Page 42: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/42.jpg)
• 2.1% of patients on spirono had a single K >6.0
![Page 43: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/43.jpg)
Pearl
• Spironolactone is the most effective 4th-line
medication by far for patients with resistant
hypertension
![Page 44: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/44.jpg)
Case:
Urolithiasis
• 44 yo man with a 4 mm leftureteral stone withouthydronephrosis, AKI,infection or sepsis
• No prior history of urolithiasis
• Meds: none
• Adequate analgesia in the ED with ketorolac IV x 1
• Vital signs and physical examination are unremarkable
![Page 45: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/45.jpg)
In addition to NSAIDs, increasing
fluids, decreasing soft drinks, and
straining urine, you recommend?
A. Nothing
B. Doxazosin
C. Hydrochlorothiazide
D. Nifedipine
E. Tamsulosin
![Page 46: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/46.jpg)
• Guidelines often recommend medical expulsive
therapy
• Based on small, single-center, lower-quality trials
and meta-analyses of same
• Placebo-controlled RCT, 1167 adults; 24 U.K.
sites
• Tamsulosin 0.4 mg, nifedipine 30 mg, or placebo
(1:1:1) daily for up to 4 weeks
• Primary outcome: spontaneous passage at 4 wk
![Page 47: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/47.jpg)
![Page 48: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/48.jpg)
Pickard et al
Outcome Tamsulosin Nifedipine Placebo
Stone passage 81% 80% 80%
# Days of pain
medication (mean)
11.6 10.7 10.5
# Days to stone
passage (mean)
16.5 16.2 15.9
• No difference regardless of stone size (<5
mm or >5 mm) or location (upper, middle,
lower)
• No differences in health status (SF-36)
![Page 49: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/49.jpg)
Pearl
• In patients with ureteral colic and small
stones, tamsulosin and nifedipine do not
appear to be effective at decreasing the
need for further treatment to achieve stone
clearance in 4 weeks
![Page 50: Papers from 2015 That Changed My Practice](https://reader031.vdocument.in/reader031/viewer/2022022417/589047021a28ab91718b4cd7/html5/thumbnails/50.jpg)
Summary:Papers that changed my practice
• In CAP, steroids decrease LOS, IV ABX, ARDS and need
for mechanical ventilation
• Mechanical thrombectomy with stent-retrievers improves
functional outcomes in stroke due to large vessel
occlusions (ICA, M1 segment)
• Spironolactone is the most effective add-on medication in
resistant HTN
• Medical expulsive therapy is not effective for small
ureteral stones <5 mm
• Patients with SVT should undergo a modified valsalva
maneuver