Geriatrics
RCT: Invasive Strategy Does Not Significantly Improve Cardiovascular Outcomes Over Conservative Management in Older Adults with NSTEMI
7 Sep, 2024 | 13:25h | UTCStudy Design and Population: This was a prospective, multicenter, randomized trial conducted across 48 sites in the UK, enrolling 1,518 patients aged 75 years or older with non-ST-segment elevation myocardial infarction (NSTEMI). Patients were randomly assigned to receive either the best available medical therapy alone (conservative strategy) or in combination with invasive treatment (coronary angiography and revascularization). The population included individuals who were frail or had high comorbidities, with a mean age of 82 years.
Main Findings: Over a median follow-up of 4.1 years, the primary outcome (a composite of cardiovascular death or nonfatal myocardial infarction) occurred in 25.6% of the invasive-strategy group and 26.3% of the conservative-strategy group (HR, 0.94; 95% CI, 0.77–1.14; P=0.53), showing no significant difference. Cardiovascular death rates were similar between the two groups, but nonfatal myocardial infarction was lower in the invasive group (11.7% vs. 15.0%; HR, 0.75; 95% CI, 0.57–0.99). Procedural complications were rare, affecting less than 1% of patients.
Implications for Practice: This trial suggests that in older adults with NSTEMI, an invasive strategy does not significantly reduce the risk of cardiovascular death or nonfatal myocardial infarction compared to a conservative approach. The findings support the consideration of conservative management in frail elderly patients or those with significant comorbidities, given the minimal additional benefit of invasive treatment.
Reference: Kunadian, V., Mossop, H., Shields, C., Bardgett, M., Watts, P., Teare, M. D., Pritchard, J., et al. (2024). Invasive treatment strategy for older patients with myocardial infarction. New England Journal of Medicine. http://doi.org/10.1056/NEJMoa2407791
Link: https://www.nejm.org/doi/10.1056/NEJMoa2407791
RCT: Edoxaban Monotherapy Reduces Bleeding Events in Atrial Fibrillation with Stable CAD Compared to Dual Therapy
7 Sep, 2024 | 13:03h | UTCStudy Design and Population: This multicenter, open-label, adjudicator-masked randomized trial enrolled 1,040 patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) across 18 sites in South Korea. Patients were randomly assigned to receive either edoxaban monotherapy (n=524) or dual antithrombotic therapy (edoxaban plus a single antiplatelet agent; n=516). The mean age was 72.1 years, with a mean CHA2DS2-VASc score of 4.3, reflecting a moderate to high stroke risk.
Main Findings: At 12 months, the primary composite outcome occurred in fewer patients in the edoxaban monotherapy group (6.8%) than in the dual therapy group (16.2%) (HR, 0.44; 95% CI, 0.30–0.65; P<0.001). The reduction was largely driven by a significantly lower incidence of major bleeding or clinically relevant non-major bleeding (4.7% vs. 14.2%; HR, 0.34; 95% CI, 0.22–0.53). In contrast, the incidence of major ischemic events was similar between the two groups.
Implications for Practice: Edoxaban monotherapy provides a safer antithrombotic option for patients with AF and stable CAD by significantly reducing bleeding without increasing ischemic events compared to dual therapy. These findings suggest that monotherapy could be a preferable long-term treatment strategy in this population.
RCT: Interruption of Oral Anticoagulation during TAVI Reduces Bleeding Without Increasing Thromboembolic Events
7 Sep, 2024 | 12:43h | UTCStudy Design and Population: This international, open-label, randomized noninferiority trial examined 858 patients undergoing transcatheter aortic-valve implantation (TAVI) who had an indication for oral anticoagulation due to concomitant diseases. Patients were randomized 1:1 to either continue or interrupt their oral anticoagulation during the procedure, with the primary outcome being a composite of cardiovascular death, stroke, myocardial infarction, major vascular complications, or major bleeding within 30 days.
Main Findings: Primary outcome events occurred in 16.5% of the continuation group and 14.8% of the interruption group, showing a non-significant risk difference of 1.7 percentage points (95% CI, -3.1 to 6.6). Thromboembolic events were similar between groups (8.8% in continuation vs. 8.2% in interruption). However, bleeding events were significantly higher in the continuation group (31.1% vs. 21.3%; risk difference, 9.8 percentage points; 95% CI, 3.9 to 15.6).
Implications for Practice: Interrupting oral anticoagulation during TAVI significantly reduces bleeding without increasing thromboembolic risks, suggesting it may be a safer strategy for patients undergoing TAVI. These findings could influence clinical decision-making regarding anticoagulation management in this population.
Reference: van Ginkel, D.J. et al. (2024). Continuation versus Interruption of Oral Anticoagulation during TAVI. The New England Journal of Medicine. https://doi.org/10.1056/NEJMoa2407794
RCT: Continuing Aspirin vs. Antiplatelet Cessation Before Surgery Did Not Reduce Ischemic Events in Patients With Coronary Stents Over 1 Year Post-Implantation
7 Sep, 2024 | 12:29h | UTCStudy Design and Population: This randomized controlled trial (ASSURE-DES) investigated the perioperative management of antiplatelet therapy in 926 patients with coronary drug-eluting stents (DES) undergoing low-to-intermediate-risk noncardiac surgery. The patients, at least one year post-stent implantation, were randomized to continue aspirin monotherapy or stop all antiplatelet therapy five days prior to surgery.
Main Findings: The study found no significant difference in the primary composite outcome (death, myocardial infarction, stent thrombosis, or stroke) between the aspirin monotherapy group (0.6%) and the no antiplatelet group (0.9%). However, minor bleeding was more frequent in the aspirin group (14.9% vs 10.1%, P=0.027), with no difference in major bleeding.
Implications for Practice: These results suggest that for stable patients with DES undergoing noncardiac surgery, temporarily discontinuing aspirin may be a safe option, as continuing aspirin did not reduce ischemic events but did increase minor bleeding risk. Further research is needed to assess outcomes in higher-risk surgical settings.
RCT: AF Screening Does Not Reduce Stroke Hospitalizations in Elderly Patients
6 Sep, 2024 | 22:18h | UTCStudy Design and Population: The GUARD-AF trial was a prospective, randomized controlled trial conducted across 149 primary care sites in the U.S. It enrolled 11,905 participants aged 70 and older, with a median age of 75 years, 56.6% of whom were female. Participants were randomized 1:1 to either screening for atrial fibrillation (AF) using a 14-day continuous electrocardiographic patch monitor or usual care. The primary outcome was all-cause stroke hospitalization, with bleeding as a key safety outcome.
Main Findings: After a median follow-up of 15.3 months, AF diagnosis was higher in the screening group (5%) compared to the usual care group (3.3%), and anticoagulation initiation was also more frequent (4.2% vs. 2.8%). However, the risk of stroke hospitalization was not significantly different between the screening and usual care groups (0.7% vs. 0.6%; HR: 1.10, 95% CI: 0.69-1.75). Similarly, there was no significant difference in bleeding risk (1.0% vs. 1.1%; HR: 0.87, 95% CI: 0.60-1.26).
Implications for Practice: The findings suggest that screening for AF using continuous electrocardiographic monitoring in elderly patients does not reduce stroke hospitalizations despite an increased detection of AF. Given the low event rates and premature termination of enrollment due to COVID-19, further studies are needed to confirm these results and explore alternative strategies for stroke prevention in this population.
2024 ESC Guidelines for the Management of Chronic Coronary Syndromes
1 Sep, 2024 | 18:49h | UTCIntroduction: The 2024 guidelines were developed by the European Society of Cardiology (ESC) with the endorsement of the European Association for Cardio-Thoracic Surgery (EACTS). These guidelines provide updated recommendations for the management of chronic coronary syndromes (CCS), focusing on the diagnosis, treatment, and long-term care of patients with stable coronary artery disease (CAD).
Key Points:
1 – History and Risk Assessment:
– Detailed assessment of cardiovascular risk factors, medical history, and symptom characteristics is essential in patients with suspected CCS.
– Symptoms like chest pain triggered by emotional stress, dyspnea on exertion, or fatigue should be considered potential angina equivalents.
2 – Diagnostic Testing:
– Coronary Computed Tomography Angiography (CCTA): Recommended as a first-line diagnostic tool for patients with low to moderate pre-test likelihood of obstructive CAD.
– Stress Imaging: Stress echocardiography, SPECT, PET, or cardiac MRI is recommended for those with moderate to high pre-test likelihood to diagnose myocardial ischemia and estimate the risk of major adverse cardiovascular events (MACE).
3 – Revascularization Indications:
– Symptom Relief: Revascularization is recommended for patients with obstructive CAD who have significant symptoms despite optimal medical therapy.
– Prognostic Benefit: Indicated in patients with left main coronary artery disease, severe three-vessel disease, or two-vessel disease including proximal left anterior descending artery stenosis, particularly if associated with reduced left ventricular function.
– High-Risk Anatomical Features: Revascularization is advised when significant stenosis is present in patients with high-risk anatomical features identified by imaging, especially if non-invasive testing shows a large area of ischemia.
4 – Lifestyle and Risk Management:
– A comprehensive approach to cardiovascular risk reduction, including lifestyle changes (e.g., smoking cessation, diet, and physical activity) and guideline-directed medical therapy, is strongly recommended.
– Home-based cardiac rehabilitation and digital health interventions are suggested to improve long-term adherence to healthy behaviors.
5 – Antianginal and Antithrombotic Therapy:
– Tailoring antianginal therapy based on individual patient characteristics, comorbidities, and local drug availability is recommended.
– Long-term antithrombotic therapy with aspirin or clopidogrel is recommended for patients with prior myocardial infarction or revascularization.
Conclusion: The 2024 ESC guidelines emphasize a patient-centered approach, integrating advanced diagnostic tools and personalized therapeutic strategies to optimize outcomes for patients with chronic coronary syndromes. The guidelines highlight the importance of detailed risk assessment, appropriate use of diagnostic imaging, clear criteria for revascularization, and a strong focus on lifestyle interventions alongside pharmacological management.
Updated ESC Hypertension Guidelines 2024: Intensified Blood Pressure Targets and New Categories – Eur Heart J
31 Aug, 2024 | 19:54h | UTCIntroduction:
The 2024 ESC Guidelines for managing elevated blood pressure (BP) and hypertension were developed by the European Society of Cardiology (ESC) and endorsed by the European Society of Endocrinology (ESE) and the European Stroke Organisation (ESO). These guidelines introduce significant updates to BP management, including more intensive treatment targets and the introduction of a new category for “Elevated BP.”
Key Points:
1 – New Intensive BP Target: For most patients receiving BP-lowering medication, the guidelines now recommend a systolic BP treatment target range of 120-129 mmHg. This marks a significant shift from previous guidelines, which suggested a less aggressive initial target.
2 – New ‘Elevated BP’ Category: The guidelines introduce a new category, “Elevated BP,” defined as a systolic BP of 120-139 mmHg and/or diastolic BP of 70-89 mmHg. This aims to identify more patients at risk of cardiovascular events, such as heart attacks and strokes, before they meet the traditional threshold for hypertension.
3 – Pragmatic BP Management: For patients who cannot tolerate the intensive BP target, the guidelines recommend aiming for a BP that is “as low as reasonably achievable” (ALARA), particularly in frail or older individuals.
4 – Lifestyle Modifications: The guidelines emphasize lifestyle interventions, including dietary changes like potassium supplementation and new exercise recommendations, as first-line strategies for managing BP.
5 – Renal Denervation: For the first time, the guidelines include recommendations on the use of renal denervation—a procedure for patients with resistant hypertension that has not responded to standard treatments. This is not recommended as a first-line treatment but may be considered in specific high-risk cases.
Conclusion:
These new guidelines represent a major update in the management of hypertension, particularly in promoting more aggressive BP targets to reduce cardiovascular risks. The inclusion of a new BP category and recommendations for renal denervation highlight the guidelines’ focus on early intervention and advanced treatment options.
2024 ESC Guidelines for the Management of Atrial Fibrillation – Eur Heart J
31 Aug, 2024 | 19:34h | UTCIntroduction: The 2024 guidelines for the management of atrial fibrillation (AF) were developed by the European Society of Cardiology (ESC) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) and other specialized associations. These guidelines aim to provide evidence-based recommendations for the diagnosis, treatment, and management of AF, with a focus on improving patient outcomes through a multidisciplinary approach.
Key Points:
1 – Patient-Centered Care and Education:
– Education directed at patients, caregivers, and healthcare professionals is essential for optimizing shared decision-making. This approach ensures that treatment options are discussed openly, considering both the benefits and risks.
2 – Comorbidity and Risk Factor Management:
– Diuretics are recommended for patients with AF, heart failure (HF), and congestion to alleviate symptoms and improve AF management.
– Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) are recommended for patients with AF and HF, regardless of left ventricular ejection fraction (LVEF), to reduce the risk of hospitalization and cardiovascular death.
3 – Stroke Prevention and Anticoagulation:
– Oral anticoagulation is recommended for all patients with clinical AF and elevated thromboembolic risk, particularly those with a CHA2DS2-VA score of 2 or more.
– Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists (VKAs) in eligible patients undergoing cardioversion.
4 – Rate and Rhythm Control:
– Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs for heart rate control in patients with AF and LVEF >40%.
– Catheter ablation is recommended as a first-line treatment option in patients with paroxysmal AF to reduce symptoms and prevent AF progression.
Conclusion: The 2024 ESC guidelines emphasize a patient-centered, multidisciplinary approach to AF management, with a strong focus on the early identification and management of comorbidities and risk factors. The guidelines also advocate for the use of DOACs in stroke prevention and recommend specific strategies for rate and rhythm control to enhance patient outcomes.
Updated Guidelines for Potentially Inappropriate Medication Use in Older Adults (2023 AGS Beers Criteria®) – J Am Geriatr Soc
31 Aug, 2024 | 19:20h | UTCIntroduction:
The American Geriatrics Society (AGS) has released the 2023 update to the AGS Beers Criteria®, a critical tool for healthcare professionals aimed at improving the safety of medication prescribing in adults aged 65 and older. The guidelines identify potentially inappropriate medications (PIMs) that should generally be avoided in older adults due to the heightened risk of adverse effects.
Key Points:
1 – Anticholinergic Drugs: First-generation antihistamines (e.g., diphenhydramine) should be avoided due to their high anticholinergic activity, which can lead to confusion, dry mouth, constipation, and other serious side effects, including increased risk of falls and dementia.
2 – Nitrofurantoin: Should be avoided in individuals with a creatinine clearance less than 30 mL/min due to the risk of pulmonary toxicity, hepatotoxicity, and peripheral neuropathy.
3 – Cardiovascular Drugs: Aspirin for primary prevention of cardiovascular disease is not recommended in older adults due to the increased risk of bleeding and lack of clear benefit. Similarly, warfarin is discouraged as an initial treatment for nonvalvular atrial fibrillation or venous thromboembolism in favor of Direct Oral Anticoagulants (DOACs) unless DOACs are contraindicated.
4 – Central Nervous System (CNS) Medications: Benzodiazepines and non-benzodiazepine receptor agonist hypnotics (“Z-drugs”) are associated with increased risks of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults and should generally be avoided.
5 – Antipsychotics: Should be avoided for the treatment of behavioral problems in dementia or delirium due to the increased risk of stroke and greater rates of cognitive decline and mortality unless required for specific psychiatric conditions like schizophrenia or bipolar disorder.
Conclusion:
The 2023 AGS Beers Criteria® continues to serve as an essential guide for minimizing the risks associated with medication use in older adults. It emphasizes the need for individualized care and the importance of weighing the benefits and risks of medications, particularly in vulnerable populations.
RCT: No Difference in Postoperative Complications Between Continuation and Discontinuation of Renin-Angiotensin System Inhibitors Before Major Surgery – JAMA
31 Aug, 2024 | 19:12h | UTCStudy Design and Population: This multicenter randomized clinical trial included 2,222 patients who had been treated with renin-angiotensin system inhibitors (RASIs) for at least 3 months and were scheduled for major noncardiac surgery at 40 hospitals in France between January 2018 and April 2023. The participants were randomly assigned to either continue RASIs until the day of surgery or to discontinue them 48 hours before surgery.
Main Findings: The trial found no significant difference in the primary outcome—a composite of all-cause mortality and major postoperative complications within 28 days—between the continuation and discontinuation groups (22% in both groups, RR 1.02, 95% CI 0.87-1.19). However, the continuation group experienced a higher incidence of intraoperative hypotension (54% vs. 41%, RR 1.31, 95% CI 1.19-1.44).
Implications for Practice: Continuation of RASIs before major noncardiac surgery does not increase the risk of postoperative mortality or major complications, but it does elevate the risk of intraoperative hypotension. Clinicians should weigh these risks when deciding whether to continue or discontinue RASIs before surgery.
RCT: Beta-Blocker Interruption Post-Myocardial Infarction Increases Cardiovascular Events Without Improving Quality of Life – N Engl J Med
31 Aug, 2024 | 19:04h | UTCStudy Design and Population: This multicenter, open-label, randomized, noninferiority trial included 3,698 patients across 49 sites in France. Participants had a history of myocardial infarction, a left ventricular ejection fraction of at least 40%, and had not experienced a cardiovascular event in the past six months. The study compared outcomes between patients who either interrupted or continued long-term beta-blocker therapy, with a minimum follow-up of one year.
Main Findings: Interruption of beta-blocker treatment resulted in a higher incidence of adverse cardiovascular events (23.8%) compared to continuation (21.1%), with a hazard ratio of 1.16 (95% CI, 1.01 to 1.33). The difference did not meet the criteria for noninferiority (P=0.44). Additionally, there was no significant improvement in quality of life among patients who discontinued beta-blockers.
Implications for Practice: The findings suggest that in patients with a history of myocardial infarction and stable cardiovascular health, continuing beta-blocker therapy is preferable to interruption. Discontinuation may increase the risk of adverse cardiovascular outcomes without offering quality of life benefits, supporting the ongoing use of beta-blockers in this population.
RCT: Methotrexate Shows Modest Pain Reduction in Knee Osteoarthritis, More Research Needed – Ann Intern Med
18 Aug, 2024 | 18:01h | UTCStudy Design and Population: This multicenter, randomized, double-blind, placebo-controlled trial evaluated the effects of oral methotrexate on 207 participants with symptomatic knee osteoarthritis (KOA) who had persistent knee pain despite prior treatments. Conducted across 15 musculoskeletal clinics in the UK from June 2014 to October 2017, participants were randomly assigned to receive either methotrexate or placebo over a 12-month period.
Main Findings: At 6 months, methotrexate resulted in a modest reduction in knee pain, with a statistically significant difference of 0.79 points on the NRS compared to placebo (95% CI, 0.08 to 1.51; P = 0.030). Small but statistically significant improvements were also noted in knee stiffness and function. However, the clinical significance of these findings remains uncertain, and potential side effects of methotrexate warrant caution.
Implications for Practice: While methotrexate may offer some symptomatic relief for patients with knee osteoarthritis who do not respond to standard treatments, the modest reduction in pain and improvement in function observed in this study may not justify its routine use given the potential for significant side effects. The small magnitude of benefit suggests that methotrexate should be considered cautiously and only in select patients. Further research is necessary to confirm these findings and to better understand the risk-benefit profile of methotrexate in this population before broader clinical adoption.
Cohort Study: Long-Term Multivitamin Use Not Linked to Reduced Mortality in Over 390,000 US Adults
18 Aug, 2024 | 15:07h | UTCtudy Design and Population: This cohort study examined the association between daily multivitamin (MV) use and mortality risk using data from three large prospective cohorts in the United States. The study included 390,124 generally healthy adults with no prior history of cancer or major chronic diseases. Participants were followed for up to 27 years, with baseline MV use assessed between 1993 and 2001 and follow-up assessments from 1998 to 2004.
Main Findings: Daily MV use was not associated with a reduction in all-cause mortality. In fact, the study found a 4% higher risk of mortality among daily MV users compared to nonusers during the first half of the follow-up period (HR, 1.04; 95% CI, 1.02-1.07), although this risk was not significant in the second half. The findings were consistent across major causes of death, including heart disease, cancer, and cerebrovascular diseases.
Implications for Practice: These findings suggest that long-term MV use does not confer a mortality benefit among generally healthy adults. Healthcare providers may need to reconsider recommending MVs for longevity purposes, as the evidence does not support their efficacy in reducing mortality risk.
Updated Guidelines on Perioperative Management of Anticoagulant and Antiplatelet Therapy for Interventional Techniques – Pain Physician
18 Aug, 2024 | 14:52h | UTCIntroduction: The American Society of Interventional Pain Physicians (ASIPP) has published updated guidelines for the perioperative management of patients undergoing interventional techniques while receiving antiplatelet and anticoagulant therapy. These guidelines are essential for clinicians to balance the risk of thromboembolism against the risk of bleeding during interventional procedures.
Key Points:
1 – Risk of Thromboembolic Events:
– Thromboembolic events have a higher risk of morbidity and mortality compared to the risk of epidural hematoma. Thus, interruption of antithrombotic therapy should be carefully considered.
2 – Risk Stratification of Procedures:
– Interventional techniques are classified into three categories based on risk: low, moderate, or high. For high-risk procedures, cessation of anticoagulant or antiplatelet therapy is recommended, whereas for low to moderate-risk procedures, therapy may continue under certain conditions.
3 – Management of Direct Oral Anticoagulants (DOACs):
– DOACs such as dabigatran, apixaban, rivaroxaban, and edoxaban should generally be discontinued for 2 days before high-risk procedures and one day for moderate-risk procedures. Adjustments are needed based on renal function, specially for dabigatran.
4 – Discontinuation of Aspirin:
– For high-risk interventional procedures, discontinuation of aspirin (81 or 325 mg) is recommended 6 days before the procedure. However, for low to moderate-risk procedures, aspirin therapy may be continued or stopped for 3 days depending on individual risk factors and clinical judgment.
5 – Discontinuation of Other Antiplatelet Agents:
– Clopidogrel (Plavix) and Prasugrel (Effient): These agents should be discontinued 6 days before high-risk procedures. For low-risk procedures, these medications can be continued.
– Ticagrelor (Brilinta): Discontinue for 5 days before high-risk procedures, with consideration of patient-specific risk factors.
6 – Timing for Restarting Therapy:
– Antithrombotic therapy should typically be resumed within 12-24 hours after low to moderate-risk procedures and within 24-48 hours after high-risk procedures, depending on bleeding risk and patient status.
7 – Shared Decision-Making:
– Decisions on whether to continue or discontinue antithrombotic therapy should involve shared decision-making between the patient, the interventional pain specialist, and other treating physicians, considering all associated risks.
Conclusion: These guidelines provide a comprehensive framework for managing the delicate balance between thromboembolic and bleeding risks in patients on anticoagulant or antiplatelet therapy undergoing interventional procedures. They emphasize the importance of personalized care and multidisciplinary collaboration.
Meta-Analysis: Effects of Psychological, Psychosocial, Pharmacological, Physical and Combined Treatments for Adults with a New Episode of Depression – eClinicalMedicine
17 Aug, 2024 | 19:49h | UTCStudy Design and Population: This systematic review and network meta-analysis examined 676 randomized controlled trials (RCTs) involving 105,477 participants, comparing psychological, psychosocial, pharmacological, physical, and combined treatments for adults with a new episode of unipolar depression. The study stratified interventions based on depressive symptom severity (less severe and more severe).
Main Findings: For less severe depression, group cognitive behavioral therapy (CBT) was the only treatment class that significantly improved depressive symptoms compared to treatment as usual (TAU). For more severe depression, effective interventions included combined individual CBT with antidepressants, individual behavioral therapies, and combined treatments like acupuncture or exercise with antidepressants. Notably, antidepressants alone did not show significant effects in less severe depression.
Implications for Practice: These findings suggest that group CBT may be an effective first-line treatment for less severe depression, while combined therapies, particularly those involving antidepressants and individual psychological interventions, are more effective in treating more severe depression. This evidence could guide clinical decision-making and inform updates to treatment guidelines.
Study Shows High Prevalence of Solid Lung Nodules in Nonsmoking Adults – Radiology
14 Aug, 2024 | 13:14h | UTCStudy Design and Population: This cohort study examined the prevalence and size distribution of solid lung nodules in a nonsmoking population from the Northern Netherlands. A total of 10,431 participants aged 45 years and older, predominantly nonsmokers, were included in the Imaging in Lifelines (ImaLife) study. The study utilized low-dose chest CT scans to detect and measure lung nodules.
Main Findings: Lung nodules were present in 42% of participants, with a higher prevalence in males (47.5%) than females (37.7%). The prevalence of clinically relevant nodules (≥100 mm³) was 11.1%, and actionable nodules (≥300 mm³) were found in 2.3% of individuals. Both prevalence and nodule size increased with age, and male participants consistently showed a higher prevalence and larger nodule sizes compared to females.
Implications for Practice: While 42% of nonsmoking adults in this Northern European cohort were found to have solid lung nodules, the incidence of lung cancer within this population is notably low. This suggests that many of the clinically relevant and even actionable nodules identified in nonsmokers are likely benign. These findings highlight the need to refine nodule management strategies for individuals at low risk of lung cancer, potentially reducing unnecessary follow-up and interventions in nonsmoking populations. Future research on lung cancer outcomes in this cohort could further inform and optimize guidelines for nodule management in low-risk groups.
2024 ACC Expert Consensus Decision Pathway on Clinical Assessment, Management, and Trajectory of Patients Hospitalized With Heart Failure – J Am Coll Cardiol
14 Aug, 2024 | 12:47h | UTCIntroduction: The American College of Cardiology (ACC) has released a focused update on the 2019 Expert Consensus Decision Pathway (ECDP) for the management of patients hospitalized with heart failure (HF). This update reflects new evidence and aligns with the latest ACC/AHA/HFSA heart failure guidelines.
Key Points:
1 – SGLT Inhibitors in Hospitalization:
– The update emphasizes the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors during hospitalization for heart failure, regardless of left ventricular ejection fraction (LVEF). These medications should be initiated early, provided the patient is hemodynamically stable and there are no contraindications such as type 1 diabetes or severe kidney dysfunction.
2 – Triage and Admission Criteria:
– Patients with a new diagnosis of HF with rapidly progressing symptoms, severe congestion, or higher disease complexity should generally be admitted from the emergency department (ED). Some low-risk patients may be managed in an observation unit or via Hospital at Home (HaH) programs.
3 – Daily Trajectory Review:
– The clinical trajectory of hospitalized HF patients should be reviewed daily to monitor for effective decongestion and the need for initiation of guideline-directed neurohormonal therapies. Adjustments should be made based on patient response.
4 – Neurohormonal Therapy Optimization:
– Strategies for optimizing neurohormonal therapies, including beta-blockers, angiotensin receptor/neprilysin inhibitors (ARNIs)/angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), and mineralocorticoid antagonists (MRAs), are updated. Therapy should be personalized based on patient tolerance, hemodynamics, and kidney function.
5 – Decongestion Strategies:
– The update provides enhanced guidance on diuretic therapy, including the use of dual nephron blockade and carbonic anhydrase inhibitors like acetazolamide for patients not responding adequately to loop diuretics.
6 – Palliative Care Integration:
– The role of palliative care has been highlighted, particularly for patients with worsening HF or those not responding to standard treatments. Early referral to palliative care can improve advance directive completion rates and reduce readmissions.
7 – Discharge and Follow-Up:
– Detailed discharge planning is crucial, including providing patients and caregivers with comprehensive information on medications, follow-up appointments, and the importance of adhering to the prescribed regimen. Telehealth may be utilized for post-discharge follow-up.
Conclusion: This focused update to the ACC ECDP provides essential guidance for the clinical management of patients hospitalized with heart failure. It emphasizes the early initiation of SGLT inhibitors, careful daily trajectory reviews, optimization of neurohormonal therapies, and the integration of palliative care. These updates aim to improve patient outcomes by addressing both short-term and long-term management strategies.
2024 Update to the ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure – J Am Coll Cardiol
14 Aug, 2024 | 12:26h | UTCIntroduction:
The American Heart Association (AHA) and American College of Cardiology (ACC) have released the 2024 update to the 2020 clinical performance and quality measures for adults with heart failure. This update aligns with the latest 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure and introduces new performance and quality measures to improve patient care.
Key Points:
1 – Performance Measures (PM):
– PM-1: Guideline-Directed Medical Therapy (GDMT) at Discharge – Initiate optimal GDMT in hospitalized heart failure patients before discharge.
– PM-2: Blood Pressure Control in HFpEF – Ensure optimal blood pressure control in patients with heart failure with preserved ejection fraction (HFpEF).
– PM-3: SGLT2 Inhibitor Use in HFrEF – Prescribe sodium-glucose cotransporter-2 inhibitors for patients with heart failure with reduced ejection fraction (HFrEF).
2 – Quality Measures (QM):
– QM-1: SGLT2 Inhibitor in HFmrEF or HFpEF – Recommend SGLT2 inhibitors for patients with mildly reduced or preserved ejection fraction.
– QM-2: Social Determinants of Health – Screen and document actions addressing social determinants of health for heart failure patients.
– QM-3: Pregnancy Counseling – Provide patient-centered counseling on contraception and pregnancy risks for individuals with cardiomyopathy.
– QM-4: Continuation of GDMT in HFimpEF – Continue GDMT in patients with heart failure with improved ejection fraction (HFimpEF).
– QM-5: Optimization of GDMT before TEER – Optimize GDMT before performing transcatheter edge-to-edge repair (TEER) for chronic secondary severe mitral regurgitation.
– QM-6: Monoclonal Protein Screening for Cardiac Amyloidosis – Ensure monoclonal protein screening in patients undergoing bone scintigraphy for suspected transthyretin cardiac amyloidosis.
3 – Emphasis on Multidisciplinary Care: The guidelines highlight the importance of addressing cardiovascular disease risks, social determinants of health, and providing comprehensive patient education, particularly concerning reproductive health in women with cardiomyopathy.
4 – Exclusions: The measures exclude patients after heart transplantation or left ventricular assist device placement and allow for patient-specific exclusions when treatment is not appropriate based on clinical evidence or patient preference.
5 – No Retired Measures: The update did not retire any measures from the 2020 set, reflecting their continued relevance.
Conclusion:
The 2024 update introduces critical new performance and quality measures that reflect the latest evidence in heart failure management. These measures aim to improve patient outcomes by emphasizing guideline-directed therapies, multidisciplinary care, and consideration of social and health determinants.
Guideline Reference:
IDSA 2024 Guidelines for Treatment of Antimicrobial-Resistant Gram-Negative Infections – Clin Infect Dis
10 Aug, 2024 | 20:16h | UTCIntroduction:
The Infectious Diseases Society of America (IDSA) has released updated guidelines in 2024 addressing the treatment of infections caused by antimicrobial-resistant (AMR) Gram-negative bacteria. These guidelines cover pathogens including extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E), AmpC β-lactamase-producing Enterobacterales (AmpC-E), carbapenem-resistant Enterobacterales (CRE), difficult-to-treat Pseudomonas aeruginosa (DTR P. aeruginosa), carbapenem-resistant Acinetobacter baumannii (CRAB), and Stenotrophomonas maltophilia.
Key Points:
1 – ESBL-E Infections:
– Preferred treatment for uncomplicated cystitis includes nitrofurantoin and TMP-SMX. Fluoroquinolones and carbapenems are alternatives but should be reserved to prevent resistance.
– For pyelonephritis or complicated urinary tract infections (cUTI), TMP-SMX, ciprofloxacin, or levofloxacin are preferred. Carbapenems are recommended when resistance precludes other options.
2 – AmpC-E Infections:
– Cefepime is suggested for treating infections caused by organisms at moderate risk of significant AmpC production (e.g., Enterobacter cloacae complex, Klebsiella aerogenes, and Citrobacter freundii).
– The use of cephamycins (e.g., cefoxitin, cefotetan) for treating ESBL-E infections is not recommended due to insufficient clinical outcome data.
3 – CRE Infections:
– Acknowledgement of increased prevalence of metallo-beta-lactamase (MBL)-producing CRE in the U.S.
– The combination of ceftazidime-avibactam and aztreonam is suggested for MBL-producing CRE, with updated dosing recommendations provided.
4 – DTR Pseudomonas aeruginosa:
– Traditional β-lactams (e.g., cefepime) with high-dose extended-infusion therapy are recommended.
– Tobramycin or amikacin, administered once daily, are alternatives for pyelonephritis or cUTI.
5 – CRAB and Stenotrophomonas maltophilia Infections:
– Sulbactam-durlobactam with meropenem or imipenem-cilastatin is the preferred treatment for CRAB.
– The order of preference for agents treating S. maltophilia includes cefiderocol, ceftazidime-avibactam, and aztreonam, among others.
Conclusion:
The 2024 IDSA guidelines provide critical updates on managing AMR Gram-negative infections, emphasizing the importance of selecting the appropriate antibiotic based on susceptibility, resistance mechanisms, and patient-specific factors. These guidelines are essential for optimizing treatment outcomes in the face of increasing antimicrobial resistance.
Reference:
New Guidelines Recommend Against Routine Vitamin D Testing and Treatment for Healthy Adults – J Clin Endocrinol Metab
4 Aug, 2024 | 19:19h | UTCIntroduction: The Endocrine Society has developed new clinical practice guidelines focused on the use of vitamin D for the prevention of various diseases. These guidelines were created by a multidisciplinary panel, including experts in adult and pediatric endocrinology, internal medicine, obstetrics and gynecology, nutrition, and epidemiology.
Key Points:
1 – Empiric Vitamin D Supplementation in Children and Adolescents:
– Recommended to prevent nutritional rickets.
– May lower the risk of respiratory tract infections.
– Dosage in trials ranged from 300 to 2000 IU daily, with an average of about 1200 IU per day.
2 – Empiric Vitamin D Supplementation or Testing in Adults Under 75:
– Not recommended for generally healthy adults without specific indications.
3 – Empiric Vitamin D Supplementation in Adults Over 75:
– Suggested due to its potential to lower the risk of mortality.
– Treatment should be empirical, no testing recommended if there are no established indications for testing (e.g., hypocalcemia).
– Recommended daily rather than intermittent high doses. Dosage in clinical trials ranged from 400 to 3333 IU daily equivalent.
4 – Vitamin D Supplementation During Pregnancy:
– Suggested to lower the risk of preeclampsia, intrauterine mortality, preterm birth, small-for-gestational-age birth, and neonatal mortality.
– Empiric supplementation recommended without routine 25(OH)D testing unless there are established indications for testing.
– Dosages in trials ranged from 600 to 5000 IU daily equivalent, with an average of about 2500 IU per day.
5 – Vitamin D and High-Risk Prediabetes:
– Suggested to reduce the progression to diabetes.
– In clinical trials, vitamin D dosages ranged from 842 to 7543 IU daily. The estimated weighted average was approximately 3500 IU per day.
6 – Routine 25(OH)D Testing:
– Not recommended for the general population, including those with obesity or dark complexion.
– No clear evidence defining optimal target levels for disease prevention.
Conclusion: These guidelines emphasize the importance of targeted vitamin D supplementation for specific age groups and conditions, while advising against routine testing for vitamin D levels in the general population. Empiric supplementation is considered beneficial, particularly in children, pregnant women, and older adults, and is feasible, cost-effective, and generally acceptable.
RCT: Pantoprazole Reduces GI Bleeding in Mechanically Ventilated ICU Patients – N Engl J Med
3 Aug, 2024 | 18:57h | UTCStudy Design and Population: This international, randomized, double-blind trial involved 4,821 critically ill adults undergoing invasive mechanical ventilation across 68 intensive care units (ICUs). Participants were assigned to receive either intravenous pantoprazole (40 mg daily) or a matching placebo. The primary efficacy outcome was the incidence of clinically significant upper gastrointestinal bleeding within 90 days, and the primary safety outcome was mortality from any cause within the same period.
Main Findings: The trial found that upper gastrointestinal bleeding occurred in 1.0% of patients treated with pantoprazole compared to 3.5% in the placebo group (hazard ratio, 0.30; 95% CI, 0.19 to 0.47; P<0.001). Mortality at 90 days was 29.1% in the pantoprazole group and 30.9% in the placebo group, showing no significant difference (hazard ratio, 0.94; 95% CI, 0.85 to 1.04; P=0.25). There were no significant differences in the rates of ventilator-associated pneumonia or Clostridioides difficile infection between the groups.
Implications for Practice: The study demonstrates that pantoprazole significantly reduces the risk of upper gastrointestinal bleeding in critically ill patients on mechanical ventilation without affecting overall mortality. This suggests that pantoprazole can be considered a safe and effective option for stress ulcer prophylaxis in this high-risk population, potentially improving patient outcomes in the ICU.
Cohort Study: Thick liquids not linked to better outcomes in hospitalized patients with dementia—further studies required – JAMA Intern Med
25 May, 2024 | 19:41h | UTC– This matched cohort study evaluated the impact of thick vs. thin liquids on clinical outcomes in 8916 hospitalized patients aged 65 and older with Alzheimer Disease and Related Dementias (ADRD) and oropharyngeal dysphagia. Conducted across 11 diverse hospitals in New York from January 2017 to September 2022, the study utilized propensity score matching to ensure comparability between the two diet groups based on demographic and clinical characteristics.
– The study found no significant difference in mortality rates between the thick and thin liquid groups (hazard ratio, 0.92; 95% CI, 0.75-1.14; P = .46). Patients on a thick liquid diet were less likely to require intubation (odds ratio [OR], 0.66; 95% CI, 0.54-0.80) but exhibited a higher incidence of respiratory complications such as pneumonia (OR, 1.73; 95% CI, 1.56-1.91).
– The findings suggest that while thick liquids may reduce the need for intubation, they may increase the risk of respiratory complications. These results underscore the necessity for future prospective studies to more definitively ascertain the effectiveness of thick liquids in improving clinical outcomes for this patient population.
Reference (link to abstract – $ for full-text):
Makhnevich, A. et al. (2024). Thick Liquids and Clinical Outcomes in Hospitalized Patients With Alzheimer Disease and Related Dementias and Dysphagia. JAMA Intern Med. Published online May 6, 2024. doi:10.1001/jamainternmed.2024.0736
Cohort Study: Efficacy of first-line color doppler ultrasound in diagnosing giant cell arteritis – Ann Intern Med
25 May, 2024 | 19:39h | UTCThis prospective multicenter study aimed to evaluate the efficacy of using color Doppler ultrasound of the temporal arteries as the first-line diagnostic tool for Giant Cell Arteritis (GCA) in 165 elderly patients with high clinical suspicion of the disease. The study followed participants over two years, comparing ultrasound results with temporal artery biopsy (TAB) and physician-based clinical diagnosis including other imaging tests. Key findings indicate that ultrasound confirmed GCA in 44% of cases, which was higher compared to TAB (17%) and clinical expertise (21%). The study showed that using ultrasound first can avoid the need for further invasive tests like TAB in patients with positive ultrasound results. The limitations of the study include its small sample size, unblinded test results, and the absence of a universally accepted objective diagnostic standard. However, it highlights the potential of ultrasound in the early and non-invasive diagnosis of GCA, potentially reducing the risk of severe complications by expediting treatment initiation.
Reference (link to abstract – $ for full-text):
RCT: Triple combination of paracetamol, ibuprofen, and dexamethasone reduces morphine use post-hip arthroplasty – Lancet Rheumatol
11 May, 2024 | 14:18h | UTCStudy Design and Population: The RECIPE trial was a randomized, blinded, placebo-controlled multicenter study conducted across nine Danish hospitals to evaluate the effectiveness of non-opioid analgesic combinations in managing postoperative pain following total hip arthroplasty. A total of 1,060 adults scheduled for surgery were enrolled and randomly assigned to one of four treatment groups, receiving combinations of paracetamol, ibuprofen, and dexamethasone. The study’s primary endpoint was the 24-hour intravenous morphine consumption, with a predefined minimal important difference set at 8 mg.
Main Findings: The trial results indicated significant reductions in 24-hour morphine consumption in the group receiving paracetamol, ibuprofen, and dexamethasone combined, compared to other groups, though none reached the minimal important difference. Specifically, this group consumed a median of 15 mg morphine, which was less than the other groups ranging from 16 mg to 24 mg. However, the differences did not meet the study’s threshold for a clinically important effect. Adverse events were lowest in the combined treatment group, suggesting a better safety profile primarily characterized by fewer incidents of nausea, vomiting, and dizziness.
Implications for Practice: The findings support the use of a combined regimen of paracetamol, ibuprofen, and dexamethasone for reducing morphine consumption post-total hip arthroplasty, which could be significant in clinical settings aiming to minimize opioid use. The improved safety profile also highlights the potential benefits of multimodal analgesia. Further research may explore the optimization of dosing schedules and long-term outcomes to enhance patient recovery and satisfaction.
Reference (link to abstract – $ for full-text):
ACP Guidelines for the pharmacologic management of type 2 diabetes in adults – Ann Intern Med
3 May, 2024 | 14:05h | UTCThe American College of Physicians (ACP) has issued an updated guideline focusing on the pharmacological management of type 2 diabetes. This guideline reviews the efficacy and safety of new medications, including GLP-1 agonists, SGLT-2 inhibitors, and others, emphasizing a systematic evaluation using the GRADE methodology. Key recommendations advise the integration of SGLT-2 inhibitors or GLP-1 agonists with metformin and lifestyle changes for better glycemic control and reduction in mortality and major cardiovascular events. Conversely, the use of DPP-4 inhibitors in similar therapeutic contexts is not recommended due to insufficient evidence of benefit. This guideline targets healthcare providers managing nonpregnant adults with type 2 diabetes.
Reference (link to free full-text):