ACP HospitalistWeekly 5-5-10
- Many stent patients delay taking clopidogrel with adverse results
- Silent PE occurs in one-third of DVT patients
- Newer assessment tool detects more post-stroke cognitive abnormalities than MMSE
- ABCD2 score can predict long-term risk of stroke recurrence
- No difference in VAP rates with early vs. late tracheotomy
- Tracheostomy tubes recalled
From ACP Hospitalist
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Many stent patients delay taking clopidogrel with adverse results
Patients who delay filling their clopidogrel prescription for even a day after discharge post-implantation of a drug-eluting stent (DES) have a higher risk of death or myocardial infarction (MI).
A retrospective cohort study included 7,402 patients who received a DES at one of three large integrated health centers. According to pharmacy records, 16% of the patients did not fill their prescriptions for clopidogrel on the day of discharge. Patients with any delay in filling clopidogrel had a higher risk of death or MI during follow up (14.2%) compared with patients who filled their prescriptions the day of discharge (7.9%), with a large proportion of the adverse events occurring within the first 30 days after discharge. Patients were less likely to fill the prescription if they were older or had more comorbidities. The study appears in the May Circulation: Cardiovascular Quality and Outcomes.
Whether patients delayed by only one day or more than five had no significant impact on their increased risk, which may be due to the loading dose, patients metabolizing clopidogrel differently or the possibility that they don’t start taking the drug the day they pick it up. The study also found that delay in filling prescriptions for statins did not increase risk, although they could not collect data on compliance with aspirin therapy. The researchers also noted that patients who delayed filling the initial clopidogrel prescription were more likely to have gaps between subsequent refills.
The study’s results may actually underestimate the degree of the problem, the authors noted, because all patients in the study had prescription drug coverage. The findings highlight the importance of ensuring that patients take clopidogrel as prescribed and thereby reduce their risk of stent thrombosis. In order to accomplish this goal, the lead author of the study said in a press release that hospitals should ensure that patients receive a follow-up phone call from a pharmacist or nurse soon after discharge, in addition to general efforts to improve the quality of discharge transitions..
Silent PE occurs in one-third of DVT patients
Silent pulmonary embolism (PE) occurs among one-third of patients with deep vein thrombosis (DVT), and routine screening would offer several advantages and disadvantages, researchers concluded from a systematic review.
Researchers identified 28 published investigations, then stratified them. Tier 1 included 12 studies in which silent PE was diagnosed by a high-probability ventilation-perfusion lung scan using criteria from the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) criteria, computed tomography pulmonary angiography, or conventional pulmonary angiography. Tier 2 included 16 studies in which silent PE was diagnosed by ventilation-perfusion lung scans based on unstated or non-PIOPED criteria. Results appeared in the May American Journal of Medicine.
Among Tier 1 studies, silent PE was detected in 703 of 2,656 patients (27%) with DVT. Among Tier 2 studies, silent PE was detected in 962 of 2,577 patients (37%) with DVT. In total, silent PE was diagnosed in 1,665 of 5,233 DVT patients (32%). Researchers considered this a conservative estimate because many studies used stringent criteria to diagnose PE.
Silent PE is more frequent in patients with proximal DVT than distal. When only those with proximal DVT were considered, the prevalence of silent PE was 600 of 2,269 (26%) in Tier 1 patients and 291 of 538 (54%) in Tier 2 patients. The overall prevalence of silent PE in patients with proximal DVT was 891 of 2,807 (32%).
In five investigations, comparisons were made of the prevalence of silent PE with proximal and distal DVT. In those with proximal DVT, silent PE occurred in 196 of 546 patients (36%) compared with 15 of 113 patients (13%) with distal DVT (P<0.0001). In an investigation of proximal DVT that extended into the pelvic veins, 69 of 139 patients (50%) showed silent PE.
- Silent PE was associated with aging. Among patients with proximal DVT, silent PE was present in 14% of those aged 40 years or less, 22% of those ages 40 to 70, and 40% of those 70 years or more.
- Larger perfusion defects occurred more frequently in patients with DVT of the thigh or pelvic veins than in those with distal DVT. Silent emboli may be extensive and involve central pulmonary arteries.
- Silent PE seemed to increase the risk of recurrent PE. Prevalence was 25 of 488 (5.1%) with silent PE compared to 7 of 1,093 (0.6%) without silent PE.
Routine screening for silent PE among DVT patients would offer a baseline for further imaging studies and a better understanding of a patient's pathophysiology, the authors said. Furthermore, hospitalization would have to be considered if a silent PE was found. Disadvantages include the costs, time and radiation exposure involved.
Newer assessment tool detects more post-stroke cognitive abnormalities than MMSE
The Montreal Cognitive Assessment (MoCA) detects substantially more cognitive abnormalities after stroke and transient ischemic attack than does the widely used Mini-Mental State Examination (MMSE), a study found.
In a prospective, population-based cohort study, English researchers administered both assessments to 493 consecutive stroke and transient ischemic attack (TIA) patients at either their six-month or five-year follow-up appointments. The MMSE was administered at the beginning and the MoCA at the end of the 30-minute appointment, along with a modified Rankin score. Normal cognitive function was defined as 27 or greater on the MMSE, and 26 or greater on the MoCA. The results were published online April 8 in Stroke.
Of the 493 patients, 413 were testable (nontestable patients were older and more likely to have had a previous cerebrovascular event, dysphasia, and dementia). In testable patients, MMSE and MoCA scores were highly correlated (r2 =0.80, P<0.001), but MoCA scores were normally distributed while MMSE scores were skewed toward higher values (ceiling effect). Two hundred ninety-one of the 413 testable patients had MoCA less than 26; of those 291, 162 had MMSE of 27 or higher. On the other hand, only five patients with normal MoCA had MMSE of less than 27 (P<0.0001). Rankin scores, which measure the degree of disability (lower scores indicate less disability), were significantly lower in patients with MMSE >27 and MoCA >26 than in those with MMSE >27 and MoCA <26, or in those with MMSE <27 (P<0.001).
Given that 58% of patients with normal MMSE had abnormal MoCA, and these patients were more dependent by the Rankin scale than those with normal MoCA, this study's findings appear clinically relevant, the authors said. The MoCA differentiated well between cognitive ability levels, and demonstrated deficits in multiple areas—like executive function, recall and repetition—that the MMSE didn't detect, the authors said. Study limitations include that the reproducibility of the MoCA wasn't formally assessed, and its sensitivity and specificity for cognitive impairment weren't determined. Also, the MoCA was always performed at the end of a patient's appointment, when fatigue may have increased the likelihood of error, the authors noted..
ABCD2 score can predict long-term risk of stroke recurrence
In addition to predicting short-term risk, the ABCD2 score can predict the risk of having another stroke up to four years after an initial minor ischemic stroke or transient ischemic attack, new research has found.
Researchers in Hong Kong followed 490 consecutive patients, for an average of 40.5 months, who had been hospitalized between January 2004 and December 2005 for transient ischemic attack (TIA) or minor stroke. Patients with atrial fibrillation were excluded, because the risk of further stroke strongly depended on warfarin use, and this drug may be underused in the Chinese population, the researchers noted. The ABCD2 score was calculated retrospectively from hospital records and from a prospective stroke registry. Results were published online April 22 in Stroke.
Fifteen and a half percent of patients had stroke during follow-up, and 12.7% of patients died. Causes of death were ischemic stroke (n=4), hemorrhagic stroke (n=2), pneumonia (n=16), cancer (n=11), ischemic heart disease (n=4), other causes (n=21) and unknown causes (n=4). Cox multivariate regression analysis found that an ABCD2 score of 4 was an independent risk factor for future stroke (hazard ratio [HR], 2.27; 95% CI, 1.36 to 3.80; P<0.001). Previous cerebral vascular disease, ischemic heart disease and smoking were independent predictors of death. The cumulative risk of later stroke was 7% at 12 months, 11% at 24 months, 15% at 36 months, 17% at 48 months, and 17% at 54 months.
While previous studies have showed the ABCD2 score can predict immediate stroke risk, the current study predicted long-term stroke or death risk up to 54 months after a TIA or minor stroke, the authors noted. Study limitations include the use of retrospective calculation of the ABCD2 score, which might be less predictive than a prospective score. For patients with elevated long-term stroke risk as identified by ABCD2 score, urgent intervention and aggressive evaluation may be warranted, the authors concluded.
No difference in VAP rates with early vs. late tracheotomy
Early tracheotomy doesn't significantly reduce the incidence of ventilator-associated pneumonia compared with late tracheotomy, nor does it lower mortality risk, a new study found.
In a randomized, controlled trial, Italian researchers recruited 600 patients from 12 ICUs from June 2004 to June 2008. Patients were age 18 or older, didn't have lung infection, had been ventilated for at least 24 hours, had a Simplified Acute Physiology Score II between 35 and 65, and had a sequential organ failure assessment (SOFA) score of at least 5. They were randomized 48 hours after enrollment to early tracheotomy (after 6 to 8 days of laryngeal intubation) or late tracheotomy (after 13 to 15 days of intubation) if their respiratory conditions worsened, if their sequential organ failure assessment score remained unchanged or worsened, and if they didn't have pneumonia. Of the 600, 419 patients met the tracheotomy criteria. The study was published in the April 21 Journal of the American Medical Association.
Of the 419 patients randomized to bedside tracheotomy, 69% in the early tracheotomy group actually received the procedure, compared to 57% in the late tracheotomy group. There was no significant difference in ventilator-associated pneumonia (VAP) rates between the early tracheotomy and late tracheotomy patients (14% vs. 21% incidence, P=0.07) 28 days after randomization. There was also no difference in length of stay, mortality at one year, and need for care at a long-term care facility. The number of ICU-free and ventilator-free days was higher in the early tracheotomy group; the adverse event rate was 39% in both groups.
The study data suggest tracheotomy shouldn't be performed earlier than after 13 to 15 days of endotracheal intubation, the authors concluded, since planning an earlier tracheotomy increased the number of patients who received a tracheotomy, and more than one-third of patients experienced an adverse event related to the tracheotomy.
Tracheostomy tubes recalled
Certain lots of cuffed Shiley tracheostomy tubes and custom/specialty tracheostomy tubes have been voluntarily recalled by manufacturer Covidien, the FDA announced last week.
The cuff on the affected tubes may not hold air as a result of leaks in the pilot balloon inflation assembly. If a cuff does not hold air, ventilation will be adversely affected since the ability to generate positive pressure in the airway could be compromised by lack of cuff seal. In some instances, this could result in serious injury, including death. The voluntary recall only affects lot numbers from a specific period of time, which are listed in the FDA press release.
From ACP Hospitalist.
Suggest a colleague as a Top Hospitalist
ACP Hospitalist is seeking candidates for our third annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2010, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, leadership, mentorship or quality improvement.
Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 16, 2010, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2010 issue.
Cartoon caption contest.
And the winner is …
ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.
"I guess we've got some bad news for each other. Do you want yours first?"
This issue's winning cartoon caption was submitted by David A. Cooke, FACP, who will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 118 ballots online to choose the winning entry. Thanks to all who voted!
The winning entry captured 54.2% of the votes.
The runners-up were:
“OK, OK, I admit it. I should have called hospice sooner.”
“You drug reps will do just about anything to get my attention.”
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