Monday, September 08, 2008

CME conference day 3

Day 3 of the Tutorials in the Tetons Update in Cardiovascular Disease took place September 1. I’m a little late posting this due to a whirlwind schedule since I returned home.

Dr. Gordon Ewy talked on hypertension, focusing on issues in clinical epidemiology and the treatment of resistant hypertension. Despite greater awareness of the problem of hypertension it remains under treated. This increased awareness has been characterized as disease mongering. Yet, the benefits of treatment to new and more aggressive targets are undisputed. The old definition of normal systolic blood pressure as “100+age” has been thoroughly debunked. He pointed out that hypertension treatment is supported by the greatest number of trials in all of medicine. Evidence is still mounting that hypertension treatment matters, even in the very old. The presentation was scientifically rigorous and free of commercial bias. Drug classes rather than drug names were emphasized. Almost all drug classes for hypertension treatment have generic drugs available.

Dr. Barry Greenberg, Professor of Medicine and Director of the Advanced Heart Failure Treatment Program at UCSD, gave a presentation on heart failure. There were several points of interest to hospitalists. Much of the new information on in patient treatment and outcomes comes from two large databases, Optimize-HF and ADHERE. From these studies we have learned that bad outcomes occur late. Whereas in patient mortality is 4%, the combined readmission and mortality rate at 60-90 days is almost 40%. In these registries the average length of hospital stay was around 4 days. That’s lower than some reports from previous years and seems awfully low to me for such desperately ill patients. These facts, combined with data from older studies that late heart failure outcomes are worse when fluid overload is incompletely treated during hospitalization raise a provocative question: are we discharging heart failure patients too soon?

A related issue is the extent to which hospitalists should adjust patients’ long term medications before discharge. We are under intense pressure to reduce length of stay. The rule of thumb is stabilize, discharge and let the out patient PCP deal with long term medications. While this approach may improve our utilization stats it may not produce the best outcomes. In an earlier presentation Greenberg cited this study showing that if beta blockers are not started in the hospital they are unlikely to be started at all. Although it was a study of patients with myocardial infarction its lessons apply to heart failure and other conditions.

Dr. Greenberg made brief mention of the Neseritide controversy and suggested we reserve judgment pending completion of the ASCEND-HF study which aims to resolve questions regarding Neseritide’s effect on 30 day mortality.

Dr. Greenberg’s presentation was balanced and free of commercial bias. No suggestion was made favoring one member of a class of drugs over another. My review of primary sources indicates that the content was scientifically rigorous.

The conference ended with bench-to-bedside discussions by Dr. Nicolas A. F. Chronos and Dr. J. Jeffrey Marshall on platelet disorders, spanning pathophysiology, aspirin and clopidogrel resistance, and a review of the new guidelines. I’ll be posting final impressions about the conference shortly.

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