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ACP HospitalistWeekly
In the News for the Week of 11-23-11
Highlights
New-onset afib in severe sepsis associated with stroke, death risk
Severe sepsis patients with new-onset atrial fibrillation (AF) had a higher risk of in-hospital stroke and death compared to those without AF or with preexisting AF. More...
Thrombolysis may benefit acute ischemic stroke patients with diabetes and prior stroke
Thrombolysis appeared to benefit patients with acute ischemic stroke who had concomitant diabetes or a history of stroke, according to a new study. More...
Cardiology
One-fourth of ICD patients don't receive optimal medical therapy perioperatively
More than a quarter of eligible patients didn't receive optimal medical therapy for congestive heart failure at the time of implantable cardiac defibrillator (ICD) implantation, a new analysis found. More...
VTE prophylaxis
Apixaban not superior to enoxaparin
In a trial of thromboprophylaxis in medical inpatients, use of apixaban resulted in only slightly lower rates of thrombosis, and more bleeding, than enoxaparin. More...
CDC update
Antibiotic tracking expands to hospitals
The CDC's electronic antibiotic tracking system has been expanded from outpatient settings to hospitals, the agency announced last week during Get Smart About Antibiotics Week. More...
From ACP Hospitalist
The next issue of ACP Hospitalist is online
The November issue of ACP Hospitalist is now online. Read about the 2011 Top Hospitalists, the best use of antipsychotics in delirium, the designer drug nicknamed "bath salts," and more. More...
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. More...
Editorial note: ACP HospitalistWeekly will not be published next week due to the Thanksgiving holiday.
Physician editor: A. Scott Keller, MD, FACP
Highlights
.
New-onset afib in severe sepsis associated with stroke, death risk
Severe sepsis patients with new-onset atrial fibrillation (AF) had a higher risk of in-hospital stroke and death compared to those without AF or with preexisting AF.
Researchers used 2007 discharge data on 49,082 adults with severe sepsis from the California State Inpatient Database, which comprises data from all patients hospitalized in nonfederal acute care hospitals in California. The mean patient age was 69 years. After excluding AF cases present at admission, new-onset AF was defined as AF or atrial flutter that occurred during the hospital stay. Severe sepsis, AF and ischemic stroke were defined by the presence of the ICD-9-CM codes for those conditions. Results were published online Nov. 13 in the Journal of the American Medical Association.
Inpatients with severe sepsis had a significantly higher risk of new-onset AF compared to inpatients without severe sepsis (adjusted odds ratio [OR], 6.82; 95% CI, 6.54 to 7.11; P<0.001). Severe sepsis patients with new-onset AF had higher risks of in-hospital stroke compared to severe sepsis patients without new-onset AF (2.6% vs. 0.6% strokes; adjusted OR, 2.70; 95% CI, 2.05 to 3.57; P<0.001). The former also had a higher risk of in-hospital death (56% vs. 39% deaths; adjusted relative risk, 1.07; 95% CI, 1.04 to 1.11; P<0.001). Within the group of severe sepsis patients without new-onset AF, those with preexisting AF had a 0.57% risk of in-hospital ischemic stroke and a 44% risk of death, while those without any AF had a 0.69% risk of stroke and a 38% risk of death. The increased stroke and mortality risks seen with new-onset AF "were robust across two definitions of severe sepsis, multiple methods of addressing confounding, and multiple sensitivity analyses," the authors noted.
Current guidelines don't address AF that occurs in the setting of severe sepsis or acute infection, which suggests that new-onset AF in this setting "is an underrecognized public health problem," the authors wrote. It's projected that one million Americans will have severe sepsis in 2011; this study suggests more than 60,000 Americans will also have new-onset AF and the associated risks of ischemic stroke and in-hospital death. If these findings are replicated, "it will be important to examine management strategies that might diminish the risk of adverse outcomes associated with AF during severe sepsis," the authors concluded.
.
Thrombolysis may benefit acute ischemic stroke patients with diabetes and prior stroke
Thrombolysis appeared to benefit patients with acute ischemic stroke who had concomitant diabetes or a history of stroke, according to a new study.
Guidelines in the U.S. and Europe have recommended that recombinant tissue plasminogen activator (rtPA) not be used in patients with diabetes or with prior stroke, although this is an area of some debate and these recommendations are not always followed in clinical practice. European researchers compared registry data to determine how diabetes and prior stroke affected outcomes of patients with acute ischemic stroke who received thrombolysis versus controls who did not. Ninety-day modified Rankin Scale scores were compared after adjustment for age and National Institutes of Health Stroke Scale (NIHSS) score at baseline. The study results were published online Nov. 16 by Neurology and appear in the Nov. 22 print issue.
Overall, data were available for 29,500 patients, 5,411 (18.5%) with diabetes, 5,019 (17.1%) with prior stroke and 1,141 (5.5%) with both. Adjusted modified Rankin Scale scores were better in treated patients than controls among those with diabetes, stroke, or both (odds ratios, 1.45, 1.55, and 1.23; P<0001 for all comparisons according to the Cochran-Mantel-Haenszel test). These results were similar to the 19,939 patients without diabetes or prior stroke, whose odds ratio for the adjusted modified Rankin Scale score was 1.53 (P<0.0001) for the comparison between treated patients and controls. Patient age (≤80 years or >80 years) did not affect outcomes.
The authors acknowledged that the data used in their study were not randomized but concluded that patients who received thrombolysis for acute ischemic stroke had better outcomes, even if they had diabetes or prior stroke, than those who did not receive the therapy. The researchers did not see a significant benefit in patients with both conditions but noted that the subgroup of these patients was small and that no interaction was observed between diabetes and prior stroke and treatment effect. Because the observed benefit of therapy in their study was similar to that seen in patients without diabetes and prior stroke, the authors concluded that there is no reason to withhold rtPA for acute ischemic stroke in patients with these conditions.
The author of an accompanying editorial reiterated the variety of opinions in this area, noting that clinicians have had many questions about how and whether recommendations about eligibility for thrombolysis should be followed. He called the current study "a concerted empirical effort" to determine whether such recommendations are valid for the significant number of patients—up to 15%—who present to the emergency department with a history of prior stroke and diabetes. "There appears to be no justification for the continued restriction of these patients from thrombolytic therapy," the editorialist concluded.
Cardiology
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One-fourth of ICD patients don't receive optimal medical therapy perioperatively
More than a quarter of eligible patients didn't receive optimal medical therapy for congestive heart failure at the time of implantable cardiac defibrillator (ICD) implantation, a new analysis found.
Using the National Cardiovascular Data Registry, researchers examined data on 175,757 patients who underwent first ICD implantation at 1,201 centers between Jan. 1, 2007 and June 30, 2009. Patients were at least 18 years old, had a left ventricular ejection fraction (LVEF) of 35% or lower, and were stratified by use of perioperative optimal medical therapy (OMT). Researchers compared patients' clinical and procedural characteristics, as well as the characteristics of the physicians implanting the ICDs and the hospitals where the procedures were performed. Results were published online Nov. 14 in the Archives of Internal Medicine.
Twenty-six percent (n=45,240) of the ICD recipients were eligible for OMT but didn't receive it. Rates were similar whether ICD placement was the primary purpose of hospitalization (24.6%) or whether the placement was for primary prevention (25.6%). Patients who did get OMT were more often younger, had hypertension, and had commercial insurance. They were less likely to have recently been hospitalized for heart failure, have a history of ischemic heart disease, or have renal dysfunction or atrioventricular node conduction abnormalities. Of patients who had coronary artery bypass graft surgery (CABG) while hospitalized (n=2,632), 65.7% were discharged on OMT, compared to 75.3% of patients (n=5,258) who underwent percutaneous coronary intervention (PCI) while hospitalized.
In multivariate analysis, higher OMT use was seen at teaching hospitals (odds ratio [OR], 1.16; 95% CI, 1.06 to 1.27) and with patients who had PCI during the admission (OR, 1.11; 95% CI, 1.04 to 1.19), a history of hypertension (OR, 1.32; 95% CI, 1.28 to 1.36), and a cardiovascular indication for admission (OR, 1.11; 95% CI, 1.04 to 1.19). Lower OMT use was seen with CABG during admission (OR, 0.66; 95% CI, 0.61 to 0.72), and an implanting physician who was board certified in surgery (OR, 0.73; 95% CI, 0.66 to 0.80). Lower OMT use was also seen in patients with medical comorbidities such as renal dysfunction and chronic lung disease and with more severe cardiovascular disease. Higher OMT rates were seen for implanting physicians with formal electrophysiology training.
The results suggest that an implanting physician's background may influence prescribing patterns and that patients whose ICDs were implanted by nonelectrophysiology clinicians should receive closer scrutiny, the authors said. Electronic decision support and standardized order sets may help with OMT guideline adherence, as may the direct involvement of a medical cardiologist in the peri-implantation setting, they wrote.
Limitations of the data registry used include that investigators didn't have information about antecedent and subsequent medication adherence or medication dosing, so the analysis provides a snapshot of medication use "at best," an invited commentary author noted. Lower use of OMT by certain physician specialties is "interesting but to some degree a distraction," as it's not clear the authors tested for covariate interactions, he added. More interesting is the finding that OMT was less common when an implant occurred during an admission that also included CABG, he said. "It is more than reasonable to inquire why a device implant occurs during a hospitalization for a revascularization procedure, which can lead to improvements in both ventricular function and the arrhythmia substrate, unless these device procedures were revisions rather than de novo implants. The latter are not recommended by current guidelines," the commenter wrote.
VTE prophylaxis
.
Apixaban not superior to enoxaparin
In a trial of thromboprophylaxis in medical inpatients, use of apixaban resulted in only slightly lower rates of thrombosis, and more bleeding, than enoxaparin.
The double-blind, double-dummy trial included more than 6,000 inpatients who were acutely medically ill, had an additional risk factor for venous thromboembolism (VTE), and were expected to stay in the hospital for at least three days. They received either oral apixaban, 2.5 mg twice a day for 30 days, or subcutaneous enoxaparin, 40 mg once a day for six to 14 days. The primary outcome was a 30-day composite of death related to VTE, pulmonary embolism, symptomatic deep vein thrombosis (DVT) or asymptomatic proximal-leg DVT, as detected by compression ultrasonography on day 30. The results were published online in the New England Journal of Medicine on Nov. 13.
Of the 2,211 patients analyzed in the apixaban group, 60 (2.71%) experienced one of the primary outcomes, compared to 70 patients (3.06%) in the 2,284-person enoxaparin group (relative risk for apixaban, 0.87; P=0.44). However, there was a significant difference between the groups in major bleeding within 30 days. In the apixaban group, 15 patients had a major bleed (0.47%) compared to six (0.19%) of the enoxaparin patients (relative risk, 2.58; P=0.04). The study authors concluded that an extended course of apixaban was not superior to a shorter course of enoxaparin.
However, they noted several major caveats about the findings. Adverse events increased in the enoxaparin group almost immediately after the drug was stopped. In this time period, when the apixaban group was still receiving therapy, the primary outcome occurred in 31 enoxaparin patients but only 18 apixaban patients. Given the continually increasing rate of events in the enoxaparin group, the study results might have been positive if apixaban had been given for more than 30 days. The authors also noted that the rate of major bleeding with apixaban was less than 0.5%. Given these findings, they said that extended apixaban therapy may still be a promising strategy.
The study also shows that the risk of VTE extends, and even increases, beyond the time of hospital discharge, the authors said. Currently, it is standard practice to stop enoxaparin at discharge, and although this study cannot justify broad policies of extended prophylaxis, it shows the need for more precise risk-stratification strategies to determine which patients would benefit from extended prophylaxis, the authors concluded.
CDC update
.
Antibiotic tracking expands to hospitals
The CDC's electronic antibiotic tracking system has been expanded from outpatient settings to hospitals, the agency announced last week during Get Smart About Antibiotics Week.
The antibiotic use tracking system is part of CDC′s National Healthcare Safety Network. The agency has funded four health departments and their academic partners to implement the tracking system in 70 hospitals. In addition, any hospital that participates in the National Healthcare Safety Network can use this tool by working directly with its pharmacy software vendor to transmit data electronically from drug administration or barcoding records. Get Smart About Antibiotics Week is an international collaboration this year, coinciding with European Antibiotic Awareness Day and Canada′s Antibiotic Awareness Week.
In addition to programs to educate consumers and clinicians about appropriate use of antibiotics, the CDC announced a partnership with the Institute for Healthcare Improvement to pilot test a tool to help hospitals with antibiotic stewardship. The pilot testing is currently under way in eight U.S. hospitals.
From ACP Hospitalist
.
The next issue of ACP Hospitalist is online
The November issue of ACP Hospitalist is now online. Featured stories include:
Top Docs. Meet our 2011 Top Hospitalists! Our fourth annual Top Docs issue recognizes leaders and teachers, innovators and mentors, researchers and pioneers.
Antipsychotics in delirium. Antipsychotics can resolve agitation in patients with delirium, but may not provide much overall benefit. Experts weigh in on best practices for their use.
Bath salts not meant for a tub. More and more patients are showing up at hospitals under the influence of a psychoactive drug mix nicknamed "bath salts." Learn to spot and treat the symptoms of use.
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.
"Medical homeless … will work for food."
This issue's winning cartoon caption was submitted by Ronald L. Ruecker, MD, FACP, from Decatur, Ill. Readers cast 109 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 49.5% of the votes.
The runners-up were:
"Hey lady, care to join my concierge practice?"
"My payor mix has got to change."
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