Tuesday, September 20, 2016

Wednesday, September 14, 2016

Stress ulcer prophylaxis: an example of a non evidence based “standard of care”

Stress ulcer prophylaxis, generally with a PPI, has long been an in house performance measure in many institutions, but the practice was never evidence based. According to this review there is equipoise for a clinical trial.

Tuesday, September 13, 2016

The emerging link between community acquired pneumonia and cardiac disease

This is a growing concern and was recently reviewed here. From the review:

Recent findings: Recent evidence suggests that a large proportion of deaths from CAP are attributable to cardiovascular disease, including sudden cardiac death, acute myocardial infarction (MI), arrhythmias and cardiac failure. Up to one-third of patients with CAP may experience cardiovascular complications within 30 days of hospital admission, while data also suggest that CAP managed in the community is associated with increased risk of acute MI. The risk is maximal within a few days of hospitalization with CAP and reduces over time. Most studies suggest that risk is still increased at 1 year, and some suggest risk continues to be increased at 10 years post-CAP. This clearly contributes to the well-recognized increased long-term mortality associated with CAP. The mechanism is not entirely clear, but recent published data have better defined the impact of the host response, including systemic inflammation and platelet activation. The contribution of Streptococcus pneumoniae has also been recently investigated, with animal studies suggesting a direct effect of S. pneumoniae on the myocardium, forming microlesions that heal with resulting myocardial fibrosis. Several studies suggest a key role for the pore-forming toxin pneumolysin in S. pneumoniae-induced cardiac toxicity.

Summary: Several therapies have been shown to improve the outcomes in cardiovascular disease, but whether these would be effective in improving outcomes in CAP is unknown. In this review, we argue that cardioprotective treatments may hold the greatest promise in terms of reducing long-term mortality in patients with CAP.

By way of background I have posted extensively about this before [1] [2] [3] [4].

Monday, September 12, 2016

Thrombocytopenia as a prognostic marker in septic shock

This paper was highlighted in ACP Hospitalist Weekly as an important study and although it is the first time thrombocytopenia has been looked at in this way in my view it is not fundamentally new or practice changing. From the paper:

Design: Prospective, multicenter, observational cohort study.

Setting: Fourteen ICUs from 10 French university teaching and nonacademic hospitals.

Patients: Consecutive adult patients with septic shock admitted between November 2009 and September 2011 were eligible.

Intervention: None.

Measurements and Main Results: Of the 1,495 eligible patients, 1,486 (99.4%) were included. Simplified Acute Physiology Score II score of greater than or equal to 56, immunosuppression, age of more than 65 years, cirrhosis, bacteremia (p less than or equal to 0.001 for each), and urinary sepsis (p = 0.005) were globally associated with an increased risk of thrombocytopenia within the first 24 hours following the onset of septic shock. Survival at day 28 estimated by the Kaplan-Meier method was lower in patients with thrombocytopenia and decreased with thrombocytopenia severity. By multivariate Cox regression, a platelet count of less than or equal to 100,000/mm3 was independently associated with a significantly increased risk of death within the 28 days following septic shock onset. The risk of death increased with the severity of thrombocytopenia (hazard ratio, 1.65; 95% CI, 1.31-2.08 for a platelet count below 50,000/mm3 vs greater than 150,000/mm3; p less than 0.0001).

Conclusions: This is the first study to investigate thrombocytopenia within the first 24 hours of septic shock onset as a prognostic marker of survival at day 28 in a large cohort of ICU patients. Measuring platelet count is inexpensive and easily feasible for the physician in routine practice, and thus, it could represent an easy "alert system" among patients in septic shock.

The last statement is not practice changing and almost sounds silly given that all patients with sepsis get at least an automated CBC which routinely includes a platelet count.

Saturday, September 10, 2016

TIMI and GRACE perform poorly in the evaluation of patients presenting with chest pain to the ER


The Thrombolysis in Myocardial Infarction (TIMI) and the Global Registry in Acute Coronary Events (GRACE) scores were largely evaluated and validated in stratifying risk of cardiovascular events in patients with chest pain and acute coronary syndrome. Our objective was to compare these 2 scores in predicting outcome in emergency department (ED) patients with undifferentiated chest pain.

Materials and methods

This was a prospective cohort study including patients presenting to 4 EDs with chest pain with nondiagnostic or normal ECG. For all included patients (n = 3125), TIMI and GRACE scores were calculated. Follow-up was conducted at 30-day and 1-year post-ED index admission...


We reported 285 (9.1%) major adverse events at 30 days and 436 (13.9%) at 1 year. In patients with low TIMI (less than or equal to 2) and GRACE (less than 109) scores, a significant proportion had major adverse events at 30 days (5% and 7.5%, respectively) and 1 year (7.9% and 12.9%, respectively). Area under ROC curve at 30 days was 0.66 (95% confidence interval [CI], 0.62-0.71) vs 0.57 (95% CI, 0.53-0.62), respectively, for TIMI and GRACE scores. At 1 year, the area under ROC was 0.67 (95% CI, 0.62-0.71) and 0.65 (95% CI, 0.60-0.70), respectively, for TIMI and GRACE scores.


The TIMI and GRACE scores are not valid in short- and long-term risk stratification in our chest pain patients.

Friday, September 09, 2016

TPA administration in patients with stroke mimic

In patients with stroke mimic one would expect a lower incidence of head bleed as compared to patients with actual stroke because their brain tissues are not as friable. Reported experience confirms that this is the case as pointed out in this review. The incidence of head bleed in stroke mimic is in fact much lower. Comforting as that may seem the perspective offered by the article warrants emphasis:

In summary, the rate of sICH in patients with stroke mimic who receive intravenous thrombolytics is low in published data, although this estimate may be lower than that observed in clinical practice.9 Patients with stroke mimics generally were younger, were women, and had lower NIHSS scores. Fully functional outcome was 3-fold more likely for patients with stroke mimic compared with that for AIS patients. However, the risk of causing harm to even 1 patient given intravenous thrombolytics in the setting of a stroke mimic is concerning,

Thursday, September 08, 2016

In ordering troponins, consider the pretest probability

From a recent paper:


In clinical practice, we progressively rely on biomarkers, without estimating the pretest probability. There is not enough support for the use of cardiac troponin (cTn) I in the management of noncardiac patients. We studied the rate at which this test was ordered, the prevalence of detection of a positive result in noncardiac patients, and the impact of this incidental finding on clinical management.


Patients admitted from December 2011 to 2013 to our community hospital with diagnosis of noncardiac disease who had positive cTn were included. Data collected included final diagnosis, patient disposition, cardiac monitoring, cardiology consult, and cardiac biomarker testing.


Cardiac troponin I was ordered for 1700 patients in our emergency department. Seven hundred fifty patients had a positive cTn. Of the 750 patients, 412 had a positive cTn without any clinical suspicion of an acute coronary syndrome. An incidental finding of a positive cTn leads to ordering of cTn on average 4 times during admission, cardiac monitoring of 379 (91.99%) patients for at least 1 day, and a cardiac consultation for 268 (63.65%) of these patients. None of these patients was candidates for an invasive cardiac intervention.

Wednesday, September 07, 2016

TTP presenting as complete heart block

Although we typically think of a pentad of manifestations of TTP and, in fact, have a treatment threshold consisting of microangiopathic hemolytic anemia and thrombocytopenia otherwise unexplained, the disease can cause manifestations in multiple organs. Here is a discussion of cardiac manifestations.

Medical and surgical treatment of primary aldosteronisn

From a recent review:

Treatments for primary aldosteronism (PA) aim to correct or prevent the deleterious consequences of hyperaldosteronism: hypertension, hypokalemia, and direct target organ damage. Patients with unilateral PA considered fit for surgery can undergo laparoscopic adrenalectomy, which significantly decreases blood pressure (BP) and medications in most cases and cures hypertension in about 40%. Mineralocorticoid receptor antagonists (MRA) are used to treat patients with bilateral PA and those with unilateral PA if surgery is not possible or not desired. Spironolactone is more potent than eplerenone, but high doses are poorly tolerated in men. MRA can be replaced or complemented with epithelial sodium channel blockers, such as amiloride. Thiazide diuretics and calcium channel blockers are used when the first-line drugs are insufficient to control BP. Dietary sodium restriction should be implemented in all cases because the deleterious consequences of hyperaldosteronism are dependent on salt loading. Several studies comparing the results of surgery and MRA have reported no differences in terms of BP, serum potassium concentration, or cardiovascular and kidney outcomes, although the benefits of treatment tend to be observed sooner with surgery. Patients with PA display relative glomerular hyperfiltration, which is reversed by specific treatment, revealing CKD in 30% of patients. However, further kidney damage is lessened by the treatment of PA.