American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP HospitalistWeekly



In the News for the Week of May 16, 2012




Highlights

Study suggests stress tests to diagnose low-risk chest pain are overused

Many patients hospitalized with low-risk chest pain undergo stress tests that may not be necessary, a new study found. More...

Score predicts hemorrhage risk in ischemic stroke patients treated with thrombolysis

Researchers developed a score to predict risk of symptomatic intracerebral hemorrhage in acute ischemic stroke patients who receive intravenous thrombolysis, a new study reported. More...


Cardiology

Criteria describe appropriate use of cardiac cath

New criteria provide guidance on when cardiac catheterization is appropriate to evaluate patients for heart disease. More...


Nephrology

New guidelines released on lupus nephritis

The American College of Rheumatology released new guidelines last week on the screening, treatment and management of lupus nephritis, the first to specifically cover this topic. More...


Education

Course on healing health care disparities through education

Medical educators are invited to attend a two-day course featuring interactive methods for achieving the recently mandated integration of cross-cultural care into medical school and residency programs. More...


From the College

Attend a chapter meeting

Clinicians can enhance their clinical skills and knowledge and network with colleagues at local ACP chapter meetings. More...


Cartoon caption contest

Put words in our mouth

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


Physician editor: A. Scott Keller, MD, FACP



Highlights


.
Study suggests stress tests to diagnose low-risk chest pain are overused

Many patients hospitalized with low-risk chest pain undergo stress tests that may not be necessary, a new study found.

Researchers performed a retrospective cohort study of 2,107 patients with chest pain who were admitted to observation status at Baystate Medical Center in Massachusetts over a two-year period in 2007 and 2008. Patients with myocardial infarction before stress testing were excluded. Researchers used administrative records to determine patient demographics, stress test type and comorbidities. For those who had an abnormal stress test result, they performed a detailed review of the discharge summary to see if the patient underwent cardiac catheterization, revascularization and/or medication changes.

Researchers also reviewed records of a random sample of 17% of the study patients and recorded chest pain characteristics and—if available—physician documentation of pretest probability of coronary artery disease (CAD). They then estimated CAD probability as low (<10%), intermediate (>10% to <90%) or high (>90%). They considered stress testing appropriate for patients at the intermediate probability level. Results were published online May 7 by Archives of Internal Medicine.

Results showed stress testing was performed in 70% of patients. The most frequently ordered type was exercise nuclear stress (46.2%), then pharmacological nuclear stress (28.4%), then exercise stress (22.9%). Of all 1,474 tests, results were abnormal in 12.5%. Stress test ordering was associated with a patient being younger than age 70 (relative risk [RR], 1.12), a patient having private insurance (RR, 1.19), and lack of housestaff coverage (RR, 1.39).

Most patients underwent stress testing regardless of pretest probability. To wit, 68% percent of patients with low pretest probability underwent stress testing, compared to 76% with intermediate probability and 86% with high probability. Pretest probability was a strong predictor of abnormal stress test results, with abnormal results in 5% of low probability patients, 13% of intermediate probability patients, and 25% of high probability patients (P for trend, 0.02).

Formal assessment of low-risk chest pain was rare in this study, the authors noted, and most patients underwent stress testing before discharge even though most were at very low risk for major cardiovascular events in the short term. Evidence-based guidelines on ordering stress tests for low-risk chest pain are needed, as are validated tools for risk stratification in the emergency department, they said. "Until then, patients with chest pain could be routinely risk stratified using existing tools…and stress tests could be reserved for those with at least an intermediate probability of disease," they wrote, which in this study would have reduced the total number of stress tests by 30%.


.
Score predicts hemorrhage risk in ischemic stroke patients treated with thrombolysis

Researchers developed a score to predict risk of symptomatic intracerebral hemorrhage in acute ischemic stroke patients who receive intravenous thrombolysis, a new study reported.

Researchers analyzed data from 31,627 patients from the Safe Implementation of Treatments in Stroke (SITS) International Stroke Thrombolysis Register who presented with stroke symptoms and were given intravenous alteplase. The outcome, symptomatic intracerebral hemorrhage (SICH), was defined as a Type 2 parenchymal hemorrhage, with deterioration in National Institutes of Health Stroke Scale (NIHSS) score of ≥4 points or death. Risk factors associated with the outcome were entered into a logistic regression model. Adjusted odds ratios for independent risk factors were converted into points that were added together to create a risk score between 0 and 12.

Overall rate of SICH was 1.8%. Researchers found 10 independent risk factors for SICH. By order of importance, they were: use of combined aspirin and clopidogrel; use of aspirin monotherapy; baseline NIHSS score ≥13 or between 7 and 12; serum glucose level ≥180 mg/dL; age ≥72 years; systolic blood pressure ≥146 mm Hg; weight ≥95 kilograms; onset-to-treatment time ≥180 minutes; and history of hypertension. The risk score showed a >70-fold graded increase in the rate of SICH for patients with a score of ≥10 points (14.3% of patients) compared with a score of 0 (0.2% of patients). Eleven percent of patients scored ≥7 points, showing a rate of SICH of ≥3.7%, or at least double the population average. The predictive ability of the score by C statistic was 0.70 in the entire population. Results were published in the May Stroke.

A method of identifying patients at low risk of SICH may encourage use of thrombolysis by reluctant nonspecialists, the authors wrote. In general, the risk score can aid clinicians, patients and family members in making decisions about using thrombolysis in acute stroke, they added. It could also be used in conjunction with biomarkers and neuroimaging, as these evolve in their ability to predict SICH, they said. External validation of the score is needed, as is a study of the clinical effect of thrombolysis across risk score categories, to assess whether patients at high risk of SICH may still be better off with treatment, they noted.



Cardiology


.
Criteria describe appropriate use of cardiac cath

New criteria provide guidance on when cardiac catheterization is appropriate to evaluate patients for heart disease. The appropriate use criteria were released last week by the American College of Cardiology Foundation and the Society for Cardiovascular Angiography and Interventions.

The expert panel that developed the criteria identified 166 possible clinical scenarios in which diagnostic catheterization might be considered and then divided them into appropriate, inappropriate and uncertain uses. Cardiac catheterization was determined to be appropriate in 75 of the situations, uncertain in 49 and inappropriate in 42. The authors noted that use of catheterization is still reasonable in the uncertain situations, so that designation should not be used as grounds for denial of reimbursement.

The criteria primarily focus on the use of catheterization to detect blockages in the arteries that are indicative of coronary artery disease (CAD), but the panel also considered a number of other areas, including arrhythmia workup, preoperative testing and possible valve disease or pulmonary hypertension.

Among other situations, the panel advised that cardiac catheterization is appropriate in patients:

  • with definite or suspected acute coronary syndrome;
  • without prior stress testing but who report symptoms and have a high pretest probability of heart disease;
  • with typical symptoms and intermediate- or high-risk findings on prior diagnostic testing.

The panel noted certain situations in which individuals should not be referred directly to cardiac catheterization. Among others, these include:

  • asymptomatic patients at low risk for CAD or without significant symptoms suggestive of heart disease;
  • stable patients preparing for non-cardiac surgery who have good functional or exercise capacity (≥4 METS without symptoms) and/or
  • stable patients preparing for low-risk non-cardiac surgery.

These criteria will be translated into order sheets and decision support tools by the writing organizations. They were developed in collaboration with the American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance and the Society of Thoracic Surgeons. The criteria were published in the May 29 Journal of the American College of Cardiology as well as in Catheterization and Cardiovascular Interventions and the Journal of Thoracic and Cardiovascular Surgery.



Nephrology


.
New guidelines released on lupus nephritis

The American College of Rheumatology released new guidelines last week on the screening, treatment and management of lupus nephritis, the first to specifically cover this topic.

According to the guidelines, 35% of adults in the U.S. with systemic lupus erythematosus have clinical signs of nephritis at diagnosis, and a total of 50% to 60% are estimated to develop nephritis in the first 10 years of the disease. African Americans and Hispanics are more likely to develop nephritis than whites, and men are more likely to develop it than women.

To provide expert advice for practicing clinicians managing patients with this condition, the American College of Rheumatology convened a task force panel to review previous guidelines, perform a systematic review of the evidence, grade the strength of the evidence, and create clinical scenarios, which were then discussed and voted on to arrive at the final recommendations.

The task force panel made recommendations in the following categories:

  • renal biopsy and histology,
  • adjunctive treatments,
  • induction of improvement in patients with disease of increasing severity,
  • maintenance of improvement in patients who respond to induction therapy,
  • modification of therapies in patients who do not respond adequately to induction therapy,
  • identification of vascular disease in patients with systemic lupus erythematosus and renal abnormalities,
  • treatment of lupus nephritis in pregnant patients and
  • monitoring activity of lupus nephritis.

The authors acknowledged that the guidelines are limited because panel members could not agree on definitions of some terms, including remission, flare and response, and also noted that no data are currently available to support specific recommendations on dosing steroids and tapering immunosuppressive drugs. They called for further research in these areas, as well as more studies on how new therapies for lupus can be used in patients with lupus nephritis.

The guidelines were published online May 3 by Arthritis Care & Research.



Education


.
Course on healing health care disparities through education

Medical educators are invited to attend a two-day course featuring interactive methods for achieving the recently mandated integration of cross-cultural care into medical school and residency programs.

The course is offered by Harvard Medical School in Boston, Oct. 12-13, 2012. ACP is endorsing this course, allowing ACP members to enjoy a $50 discount on registration. More information is online.



From the College


.
Attend a chapter meeting

Clinicians can enhance their clinical skills and knowledge and network with colleagues at local ACP chapter meetings.

ACP members and nonmembers alike can gain insight into recent medical advances, discuss local and national issues affecting internal medicine, and learn about the benefits of membership. ACP chapter meetings will help clinicians meet not only their needs as general internists, subspecialty internists, family practitioners, fellows in subspecialty training, allied health practitioners, or residents, but also the needs of the patients they serve. More information about upcoming meetings, CME offerings and registration is available online.



Cartoon caption contest


.
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.

acph-20120516-cartoon.jpg

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





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