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ACP HospitalistWeekly 12-9-09

Highlights

• Risk of VTE high in middle-aged women following surgery
• New guidelines summarize best evidence on red blood cell transfusion

Cardiology

• PCI use on STEMI patients varies widely among hospitals
• Hospitals keep door-to-balloon time below 90 minutes for more patients

Nephrology

• Simple tool effective in predicting mortality for dialysis patients

FDA update

• Depression drug gets cardiac warning

From the College

• Council of Young Physicians now recruiting

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

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Highlights

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Risk of VTE high in middle-aged women following surgery

Middle-aged women have a significantly increased risk of venous thromboembolism for up to three months following surgery, a study reported.

Researchers used data from the Million Women Study to determine the risk of venous thromboembolism (VTE) following different types of surgery. Compared with women who did not have surgery, women who had an inpatient operation were 70 times more likely to be admitted with VTE in the first six weeks following surgery, while women who had day surgery were 10 times more likely to develop VTE. Risks remained high for up to 12 weeks post-surgery, but peaked in the third week. Women who had hip or knee replacement or cancer surgery had the highest relative risks of developing VTE. The results were published online Dec. 3 in BMJ.

The risk of VTE post-surgery remained elevated for up to a year, noted an accompanying editorial. This is important considering that most patients only receive preventive treatment for the days they are in the hospital, meaning that thromboprophylaxis often stops before the peak incidence of VTE, the editorialist said. It is also significant that day patients had increased risk, suggesting that preventive treatment should be more widely used in day case patients.

Current evidence suggests that thromboprophylaxis is needed for at least seven to 10 days for inpatients undergoing many orthopedic, general surgery and cancer surgery procedures, the editorial continued. Prolonged prophylaxis up to five weeks has also shown benefit in high-risk patients, and the current findings suggest that it should be extended for even longer periods. The editorialist urged further research on the risks of VTE and preventive treatments in a wider range of patients, including those without additional risk factors for VTE.

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New guidelines summarize best evidence on red blood cell transfusion

New guidelines on thresholds for red blood cell transfusion distill the best current evidence for common clinical situations faced in the ICU.

The guidelines, developed by a joint task force of the Eastern Association for Surgery of Trauma and the American College of Critical Care Medicine, divide recommendations on red blood cell (RBC) transfusion into seven categories: the general critically ill patient; sepsis; acute lung injury and acute respiratory distress syndrome; neurologic injury and diseases; transfusion risks; alternatives to transfusion; and strategies to reduce transfusion. The complete guidelines are published in the December Critical Care Medicine.

The guidelines depend heavily on the 10-year-old Transfusion Requirements in Critical Care Trial, which found that a restrictive transfusion strategy was at least as effective as a liberal one, said an accompanying editorial. The recommendations also question current guidelines on sepsis that recommend transfusing packed red cells if necessary to hematocrit of >30%, citing multiple studies that failed to find benefit from transfusion in septic patients, the editorial noted.

Of importance, the new guidelines point out that the evidence is insufficient to support a more liberal transfusion strategy in areas of continued controversy, such as sepsis, acute lung injury, acute respiratory distress syndrome, acute coronary syndromes and neurologic injury. The guidelines provide the clearest direction to date, the editorial continued, until there are more data on the short- and long-term risks and benefits of transfusion.

Some of the task force’s recommendations include:

• For the general critically ill patient, transfusion is indicated for patients with evidence of hemorrhagic shock and may be indicated for patients with acute hemorrhage and hemodynamic instability or inadequate oxygen delivery. (Level 1)
• In general critically ill patients, a restrictive strategy of transfusion (Hb <7 g/dL) is as effective as a liberal strategy (Hb <10 g/dL) in patients with hemodynamically stable anemia, except possibly those with acute myocardial ischemia. (Level 1)
• Transfusion needs for sepsis patients must be assessed individually because optimal transfusion triggers are not known and there is no clear evidence that blood transfusion increases tissue oxygenation. (Level 2)
• All efforts should be made to avoid transfusion in patients at risk for acute lung injury and acute respiratory distress syndrome after resuscitation. (Level 2)
• There is no benefit of a liberal transfusion strategy in patients with moderate-to-severe traumatic brain injury. (Level 2)
• Transfusion is associated with increased nosocomial infection. (Level 2)

Cardiology

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PCI use on STEMI patients varies widely among hospitals

Hospitals that are capable of performing percutaneous coronary intervention (PCI) on ST-segment elevation myocardial infarction (STEMI) patients don't always do so, and certain clinical factors make PCI use less likely, a new study found.

Researchers analyzed STEMI patients in the National Registry of Myocardial Infarction who were at PCI-capable hospitals between July 1, 2000, and December 31, 2006. At the 444 hospitals, 25,579 patients received primary PCI and 14,332 received fibrinolytic therapy. While overall PCI use increased over the study period, reperfusion strategies varied widely among hospitals. The study was published in the November 30 Circulation online.

The strongest association was for patients who presented on weekends and in the evening; they had an approximately 70% lower likelihood of undergoing primary PCI (P<0.0001; adjusted odds ratio, 0.27; 95% CI, 0.25 to 0.29). Cardiogenic shock was associated with greater use of primary PCI (P<0.0001; OR, 2.14; 95% CI, 1.72 to 2.66), as was delayed presentation (P<0.0001; OR, 1.18; 95% CI, 1.09 to 1.27)—although nearly 25% of patients with the former received fibrinolytic therapy. Being female, older than 85 years, or nonwhite also wasn't associated with increased PCI use, despite the fact that all three are risk factors for intracranial hemorrhage after fibrinolytic therapy. A Thrombolysis in Myocardial Infarction risk score >5 wasn't associated with greater PCI use, either.

The finding that off-hours presentation was associated with a lower likelihood of undergoing PCI may partially reflect the expectation of long time-to-treatment delays, thus "leading to the appropriate selection of fibrinolytic therapy," the authors said. Because there was no interaction between key clinical factors in the PCI-preferred group and the time of hospital arrival, it appears the use of PCI during off-hours wasn't being reserved for patients most likely to benefit, they added.

It is "concerning" that being elderly and nonwhite is associated with lower use of PCI, though this is consistent with previous research on disparities, the authors said. Study limitations include its observational nature and the inability to account for why a given reperfusion decision was made by an individual clinician, they noted.

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Hospitals keep door-to-balloon time below 90 minutes for more patients

Following the launch of a national program to reduce door-to-balloon times for heart attack patients, hospitals increased to 76% those eligible patients who received angioplasty within 90 minutes of hospital arrival, with rates rising by more than 10% annually for several years, a new study found.

The Door-to-Balloon (D2B) Alliance, a group of 39 organizations, launched the program in November 2006 to help hospitals lower D2B times for ST-segment elevation myocardial infarction (STEMI) patients to within 90 minutes. Study authors evaluated D2B times at 831 hospitals between April 1, 2005, and March 31, 2008, to examine changes in D2B times before and after the program was implemented, and differences in times for patients treated at hospitals participating in the program versus patients at non-participating hospitals. Program strategies included having a single call activate the cath lab and having the cath lab team arrive within 30 minutes of the call. The article is published in the December 2 online Journal of the American College of Cardiology.

By March 2008, 76% of STEMI patients received PCI within 90 minutes, compared to 62.8% in 2006 before the program was launched, and 52.5% in 2005. Patients treated in hospitals enrolled in the D2B Alliance program for more than three months were significantly more likely than those in non-participating hospitals to have D2B times within 90 minutes (P=0.001; odds ratio: 1.16; 95% CI, 1.07 to 1.27), although the magnitude of the difference was modest. Reported use of each strategy recommended by the Alliance increased significantly (P<0.001) from enrollment to follow-up in participating hospitals. Cumulatively, over the 17 total months after the start of the D2B Alliance, 75% of patients in participating hospitals had D2B times within 90 minutes, compared to 69% of non-participating hospitals.

It's difficult to determine the precise role the D2B Alliance campaign played in reducing D2B times, the authors said. The program enrolled more than 70% of hospitals that perform PCI, and its educational materials—such as webinars and newsletters—were publicly accessible. "Spillover and herd effects, which could result in widespread improvement beyond those officially enrolled, are likely," the authors noted. As well, guideline revisions and publication of research evidence may have played a role in D2B times, they said. Regardless of the cause, the improved timeliness of care is an impressive achievement, they concluded.

Nephrology

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Simple tool effective in predicting mortality for dialysis patients

A simple five-point prognostic tool was effective in predicting six-month survival of patients with end-stage renal disease, a recent study reported.

Researchers monitored survival for up to 24 months of 512 patients at five dialysis clinics and then tested the prognostic model with a validation cohort of 514 patients at eight clinics. Five variables were independently associated with early mortality: older age, dementia, peripheral vascular disease, decreased albumin and a response of "no" to a “surprise question” (nephrologists were asked "Would I be surprised if this patient died within the next six months?"). The results were published online Dec. 3 in the Clinical Journal of the American Society of Nephrology.

Nephrologists are often hesitant to give a prognosis for dialysis patients due to the questionable accuracy of existing prediction tools, the authors noted. The new predictive model, which showed a relatively high level of accuracy, represents a potentially valuable tool for physicians to identify patients with a poor prognosis who could benefit from palliative care and support services, the authors said.

The surprise question is an innovative aspect of the new model and played a key role in the accurate risk stratification of patients, researchers said. At the end of the study, almost 55% of patients nephrologists classified into the “No” group had died compared with 17% in the “Yes” group.

The new prognostic model is more specific and sensitive than any one of its components and is a significant improvement over existing methods at predicting survival of patients on dialysis, researchers concluded. They noted that future research should focus on other instruments that combine actuarial and clinical estimates of survival.

FDA update

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Depression drug gets cardiac warning

A warning has been added to the label for depression medication desipramine hydrochloride (Norpramin), the FDA announced last week.

According to the new safety information, extreme caution should be used when this drug is given to patients who have a family history of sudden death, cardiac dysrhythmias, and cardiac conduction disturbances. The warning also notes that seizures precede cardiac dysrhythmias and death in some patients.

From the College

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Council of Young Physicians now recruiting

The Council of Young Physicians (CYP) is currently recruiting four new representatives to represent the following U.S. regions for three-year terms: Northeast, Midwest, South and West.

Young physician hospitalists who are active locally are encouraged to run. ACP defines a young physician as any ACP Member or Fellow who is within 16 years of medical school graduation and no longer in training.

The CYP is responsible for planning programs for the annual meeting for young physicians and providing a young physician perspective on current issues impacting the field of internal medicine. Think you might qualify? For more information, please visit our Web site.

Cartoon caption contest

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Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries to acphospitalist@acponline.org. ACP staff will choose three finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

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