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HospitalistWeekly 7-30-08

Cardiology

• Patients' characteristics may predict outcomes in hospitalizations for heart failure

Preoperative assessment

• Simple test can help uncover alcohol disorders before surgery

Nephrology

• Appropriate medication use may be less likely in patients with kidney disease after myocardial infarction

FDA news

• New test can identify patients with warfarin sensitivity

From ACP Internist

• What they're saying on the blog

Cartoon caption contest

• Put words in our mouth: Vote for your favorite entry

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Cardiology

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Patients' characteristics may predict outcomes in hospitalizations for heart failure

Patients with certain characteristics may be at higher risk for death during heart failure hospitalization, according to a new study.

Researchers used data from OPTIMIZE-HF to examine factors associated with in-hospital mortality in patients hospitalized for heart failure. Of 45 possible predictor variables, those deemed significant in stepwise logistic regression underwent multivariate analysis. The goal was to develop a clinical predictive model for this patient population. The study appears in the July 29 Journal of the American College of Cardiology.

A total of 48,612 patients with a mean age of approximately 73 years were enrolled in the OPTIMIZE-HF trial. Of these, slightly over half were women and approximately three-quarters were white. Approximately 4% (1,834 patients) died in the hospital. Age, heart rate, systolic blood pressure, sodium and creatinine levels, primary hospitalization for heart failure and presence or absence of left ventricular systolic dysfunction were found to predict in-hospital death, with the strongest associations seen for serum creatinine at admission, systolic blood pressure at admission, and age. On the basis of these variables, the authors developed a risk-prediction nomogram to evaluate likelihood of death in patients hospitalized for heart failure.

Although the authors found that their nomogram compared favorably with results from previously published trials, they acknowledged that their study did not examine outcomes after hospital discharge and that OPTIMIZE-HF was not a randomized trial, among other limitations. However, they concluded that their scoring method could help to identify patients hospitalized with heart failure who are at high risk for death and might benefit from intensive monitoring. The authors called for further evaluation of their score to determine its impact on both clinical outcomes and patient care. The risk-prediction nomogram is available online.

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Preoperative assessment

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Simple test can help uncover alcohol disorders before surgery

Alcohol use disorder (AUD) is often overlooked before patients go into surgery, increasing the risk of complications, a recent study reported. However, a simple computerized test was effective in identifying patients at risk.

In the study, 1,556 surgical patients were asked to complete the Alcohol Use Disorder Identification Test on a computer. The authors then did a retrospective analysis and found that the prevalence of AUDs determined by the anesthesiologists was 6.9%, but 18.1% of patients tested positive for AUD using the computerized test. Physicians were more likely to detect AUD in men than in women and in older versus younger patients. The findings are published in the August issue of Anesthesiology.

The test may have been more successful at identifying AUD because patients liked the anonymity, said researchers in a news release. However, many physicians neglected to use well-documented tools for AUD detection, perhaps because they were uncomfortable questioning patients about alcohol use, the researchers said. Physicians also tended to underestimate or overlook AUD in younger patients and females, they said.

The results are important because patients with AUD have three to four times more complications during and around the time of surgery than other patients, said the news release. Better detection of AUD could also lead to earlier intervention and treatment.

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Nephrology

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Appropriate medication use may be less likely in patients with kidney disease after myocardial infarction

Patients with kidney disease may be less likely to receive appropriate medications after a myocardial infarction (MI), according to a recent report.

Researchers at Brigham and Women's Hospital performed a retrospective cohort study to determine whether medication use and adherence differed by kidney function after an MI. Use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs), statins, and beta-blockers was compared in 21,484 patients with chronic kidney disease, end-stage renal disease (ESRD) or no kidney disease who were hospitalized for MI between 1995 and 2004. The study was published online July 8 by the Clinical Journal of the American Society of Nephrology and will appear in its September issue.

Four hundred thirty-six patients (2%) had ESRD and were receiving long-term dialysis, 3,645 (17%) had chronic kidney disease, and 17,403 (81%) had no chronic kidney disease. Within 30 days after discharge, patients with chronic kidney disease had 22% lower adjusted use of ACE inhibitors/ARBs versus those without, although rates of beta-blocker and statin use were similar between the two groups. Rates of ACE inhibitor/ARB use and statin use were 43% lower and 17% lower, respectively, in patients with ESRD than in patients without chronic kidney disease. Among all patients, adherence was good at one year for 64% of those taking beta-blockers, 57% of those taking statins, and 54% of those taking ACE inhibitors/ARBs. Patients with chronic kidney disease and those without had similar rates of adherence for all drugs, although good adherence rates for beta-blockers were less common among patients with ESRD.

The authors acknowledged that their study was limited by its retrospective design and its lack of laboratory measures to determine kidney disease, among other factors. However, they concluded that use of the study drugs is suboptimal after MI in patients with and without chronic kidney disease and that patients with ESRD are least likely to receive appropriate medication. The study results could improve understanding of medications' effect on the relationship between kidney disease and cardiovascular disease, said an American Society of Nephrology press release.

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FDA news

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New test can identify patients with warfarin sensitivity

The FDA last week approved a test to identify patients who may be sensitive to warfarin (Coumadin).

Osmetech’s eSensor Warfarin Sensitivity Test detects the three genetic markers known to play a critical role in metabolism of warfarin, which in turn can help physicians decide on a dosage level for patients, the manufacturer said in a news release. The test is available now.

Warfarin is the second-most-likely drug to cause adverse events requiring hospitalization. Last year, the FDA approved updated labeling for warfarin that required manufacturers to explain that a person’s genetic makeup may influence his or her response to the drug.

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From ACP Internist

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What they're saying on the blog

Join ACP Internist's community on its blog, featuring daily updates on news that just can't wait. Find popular features such as entries on pacemakers for centenarians, mandatory e-prescribing, and the latest Medical News of the Obvious. Post your comments today.

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Cartoon caption contest

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Put words in our mouth: Vote for your favorite entry

Our cartoon caption contest continues. ACP Hospitalist staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.

Go online to view the cartoon and pick the winner, who receives a $50 gift certificate good for any ACP product, program or service.

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