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ACP HospitalistWeekly

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In the News for the Week of August 1, 2012

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Highlights

MI risk higher after total hip, knee replacement

Patients who have total hip or total knee replacement surgery are at higher risk for myocardial infarction (MI) afterward, according to a new study. More...

Several types of myocardial dysfunction common in sepsis patients

Myocardial dysfunction is frequent in patients with severe sepsis or septic shock, and has a wide spectrum of types, a new study found. More...

Sepsis

Spouses of severe sepsis patients are at risk of depression, study finds

Spouses of patients with severe sepsis may benefit from depression screening and support, particularly wives, a new study suggests. More...

Pulmonary embolism

Risk score helps determine 30-day mortality in patients with cancer and PE

A simple risk score may help determine 30-day mortality risk in patients with active cancer and acute pulmonary embolism (PE), a new study has found. 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...

Physician editor: A. Scott Keller, MD, FACP

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Highlights

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MI risk higher after total hip, knee replacement

Patients who have total hip or total knee replacement surgery are at higher risk for myocardial infarction (MI) afterward, according to a new study.

Researchers performed a retrospective cohort study using data from national registries in Denmark to compare the timing of MI in patients who had total knee or total hip replacement with that of matched controls. Patients who had a primary total knee or total hip replacement surgery from Jan. 1, 1998 through Dec. 31, 2007 were each matched by age, sex and geographic region with three controls who had not had surgery. Controls and patients were all followed for acute MI. Hazard ratios (HRs) were calculated and adjusted for disease and medication history. The study results were published online July 23 by Archives of Internal Medicine.

A total of 95,227 patients were included in the study, 66,524 who had total hip replacement and 28,703 who had total knee replacement. They were matched with 286,165 controls. Total hip patients had a mean age of 71.9 years, and 39.6% were men; total knee patients had a mean age of 67.2 years, and 37.6% were men. Within the first two weeks after surgery, total hip patients and total knee patients had a higher risk for MI compared with controls (adjusted HRs, 25.5 and 30.9, respectively). Total hip patients continued to have an elevated risk two to six weeks after surgery (adjusted HR, 5.05), but risk in total knee patients did not differ from controls after two weeks had passed. Total hip patients had an absolute six-week risk for MI of 0.51%, compared with 0.21% in total knee patients.

The authors noted that they did not have data on other risk factors for acute MI, such as body mass index and smoking; inpatient use of anticoagulant medications; or use of general anesthesia, among other limitations. However, they concluded that compared with controls, patients who undergo total hip or total knee replacement surgery have a much higher risk for acute MI within the first two postoperative weeks. "Risk assessment of [acute] MI should be considered during the first 6 weeks after THR surgery and during the first 2 weeks after TKR surgery," the authors wrote.

An accompanying commentary pointed out that cardiac risk is higher in general after surgery and said that physicians must actively work to decrease that risk. "It is important for physicians caring for patients in the perioperative period to recognize the potential for cardiac morbidity and mortality and then appropriately use the armamentarium of medical therapies we now have to reduce cardiac risk, prevent perioperative MIs, and prevent cardiac deaths," the commentary author wrote.

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Several types of myocardial dysfunction common in sepsis patients

Myocardial dysfunction is frequent in patients with severe sepsis or septic shock, and has a wide spectrum of types, a new study found.

In a prospective study, researchers examined 106 patients who were admitted to three ICUs at Mayo Clinic from Aug. 1, 2007 to Jan. 31, 2009. The patients met criteria for new-onset sepsis as defined by the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Severe sepsis was defined as sepsis associated with organ dysfunction, hypoperfusion, or hypotension. All patients enrolled received a transthoracic echocardiographic evaluation within 24 hours of meeting sepsis criteria. Myocardial dysfunction was defined as left ventricular (LV) diastolic, LV systolic or right ventricular (RV) dysfunction. Frequency of myocardial dysfunction was calculated, and mortality rates of those with and without dysfunction were compared.

Sixty-four percent of patients with severe sepsis or septic shock also had myocardial dysfunction. Thirty-seven percent of all sepsis patients had LV diastolic dysfunction, 27% had LV systolic dysfunction and 31% had RV dysfunction. Overall mortality rates were 36% at 30 days and 57% at one year, with no difference in mortality between patients with normal myocardial function and those with dysfunction. Results were published in the July Mayo Clinic Proceedings.

The study confirmed that myocardial dysfunction is frequent in patients with severe sepsis and septic shock and presents in a spectrum that includes LV diastolic, LV systolic and RV dysfunction. As such, the current practice of using decreased LV ejection fraction as the sole criterion for determining cardiac dysfunction in sepsis "is inaccurate and misleading," the authors wrote. Echocardiography is useful to help diagnose the specific type of myocardial dysfunction in sepsis and may aid in patient management, they suggested.

Sepsis

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Spouses of severe sepsis patients are at risk of depression, study finds

Spouses of patients with severe sepsis may benefit from depression screening and support, particularly wives, a new study suggests.

Researchers used data from 929 patient-spouse dyads comprising 1,212 severe sepsis hospitalizations between 1993 and 2008. Subjects were older than 50 years and had been interviewed as part of the ongoing Health and Retirement Study. Researchers identified severe sepsis using a validated algorithm in Medicare claims; they assessed depression with a modified version of the Center for Epidemiologic Studies Depression Scale; and they stratified all analyses by gender. Results were published in August's Critical Care Medicine.

In wives of patients with severe sepsis, the prevalence of substantial depressive symptoms increased by 14 percentage points, from 20% at a median of 1.1 years presepsis to 34% at a median of one year postsepsis (odds ratio [OR], 3.74). Husbands had an eight percentage point increase, which wasn't significant (OR, 1.90). Women had elevated odds of substantial depressive symptoms even when their spouses survived sepsis hospitalization (OR, 2.86), meaning the effect cannot be explained by bereavement, the authors noted. Wives of sepsis survivors who were disabled were more likely to be depressed, as well, with the likelihood increasing as the level of disability rose.

Though the data on depression in wives were clear, the association for husbands was less definitive, the authors noted, adding that older men may be less likely to report depressive symptoms. In general, the findings suggest clinicians should consider support and mental health screening for spouses, and take heed that postdischarge care instructions can burden spouses, they wrote.

Pulmonary embolism

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Risk score helps determine 30-day mortality in patients with cancer and PE

A simple risk score may help determine 30-day mortality risk in patients with active cancer and acute pulmonary embolism (PE), a new study has found.

Researchers in Spain sought to develop a risk score for 30-day mortality in patients with cancer and PE using data obtainable at PE diagnosis. They randomly allocated consecutive patients from the Computerized Registry of Patients with Venous Thromboembolism (RIETE) to a derivation cohort and an internal validation cohort. An external validation cohort of patients with cancer and acute PE was also used. The study's primary outcome was all-cause mortality 30 days after acute symptomatic PE was diagnosed, while the secondary outcome was a composite of all-cause mortality, nonfatal major bleeding or nonfatal recurrent venous thromboembolism in the same time period. Outcomes were compared in the derivation and validation cohorts. The study results were published online July 17 by Chest.

The derivation cohort included 1,048 patients, and the internal validation cohort included 508 patients. Two hundred sixty-one patients were included in the external validation cohort. In the derivation cohort, six variables were found to help predict 30-day mortality risk:

• age older than 80,
• heart rate of 110 beats/min or higher,
• systolic blood pressure less than 100 mm Hg,
• body weight less than 60 kg,
• recent immobility, and
• presence of metastases.

In the internal validation cohort, the 22.2% of patients classified as low risk by the score had a 30-day mortality rate of 4.4%, compared with 29.9% in the high-risk group. In the external validation cohort, the 18% of patients classified as low risk by the score had a 0% 30-day mortality rate, compared with 19.6% in the high-risk group.

The authors acknowledged that information bias, missing data and residual confounding were possible, among other limitations, and called for further studies that would examine the effect of the prediction model on patient management. However, they concluded that the score they developed could accurately identify patients with cancer and PE who were at low risk for death, and "might facilitate acute management of these patients on an outpatient basis."

Cartoon caption contest

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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.

"So your staff informed me that you suddenly had an opening this morning, which was such a relief 'cause I was like, 'Me too.'"

This issue's winning cartoon caption was submitted by Joseph Brett West, MD, ACP Associate Member, Phoenix, Ariz. Thanks to all who voted! The winning entry captured 49.4% of the votes.

The runners-up were:

"But ibuprofen is working great for my arthritis!"

"These new bariatric surgeries are getting ridiculous."

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