Chronic tachycardia induced cardiomyopathy

An update on this topic recently appeared in JACC.

First a little background. This was the topic of one of my very first blog posts almost 12 years ago.

Decades ago this entity was described in patients with incessant forms of SVT (eg long RP or “fast-slow reentry” tachycardias. Some of these were also ectopic atrial tachycardias). These patients had heart failure with low ejection fractions and some were cured after ablation. (See here). It wasn’t until much later when it was recognized that this entity could result from longstanding uncontrolled atrial fibrillation. Prior to that time many patients were labeled as “idiopathic” DCM with atrial fibrillation as a result. It is now recognized that the reverse is often true. That is, a DCM might evolve in a patient who started with “lone” AF. It is a chronic process. Many affected patients seem to lack cardiac awareness, thus allowing them to go for long periods with high rate atrial fibrillation.

Over time it was recognized that this was more common and occurred with varying severity. There has been some evidence, for example, that the most aggressive rate control strategy, AVN ablation and pacing, may modestly improve EF (counterbalanced, of course, by the adverse effects of RV pacing unless biV pacing is part of the management strategy).

Now on the the paper, which reported distinct inflammatory and ultrastructural patterns. From the abstract:

Results Patients with TCM, on the basis of clinical criteria, had stronger myocardial expression of major histocompatibility complex class II molecule and enhanced infiltration of CD68+ macrophages compared with patients with DCM. Furthermore, when compared with patients with ICM, the presence of T cells and macrophages was significantly reduced in TCM. Myocardial fibrosis was detected to a significantly lower degree in patients with TCM compared with patients with DCM and ICM. Electron microscopic examination revealed severe structural changes in patients with TCM. A disturbed distribution pattern of mitochondria was predominantly present in TCM. Quantitative assessment of myocyte morphology revealed significantly enhanced myocyte size compared with patients with ICM. Ribonucleic acid expression analysis identified changes in metabolic pathways among the patient groups.

Conclusions TCM is characterized by changes in cardiomyocyte and mitochondrial morphology accompanied by a macrophage-dominated cardiac inflammation. Thus, further prospective studies are warranted to characterize patients with TCM by endomyocardial biopsy more clearly.

The accompanying audio file, available as open access on the abstract page, discusses a related editorial in the same issue.

An evidence summary on severe asymptomatic hypertension

From the article:

Hypertension affects one-third of Americans and is a significant modifiable risk factor for cardiovascular disease, stroke, renal disease, and death. Severe asymptomatic hypertension is defined as severely elevated blood pressure (180 mm Hg or more systolic, or 110 mm Hg or more diastolic) without symptoms of acute target organ injury. The short-term risks of acute target organ injury and major adverse cardiovascular events are low in this population, whereas hypertensive emergencies manifest as acute target organ injury requiring immediate hospitalization. Individuals with severe asymptomatic hypertension often have preexisting poorly controlled hypertension and usually can be managed in the outpatient setting. Immediate diagnostic testing rarely alters short-term management, and blood pressure control is best achieved with initiation or adjustment of antihypertensive therapy. Aggressive lowering of blood pressure should be avoided, and the use of parenteral medications is not indicated. Current recommendations are to gradually reduce blood pressure over several days to weeks. Patients with escalating blood pressure, manifestation of acute target organ injury, or lack of compliance with treatment should be considered for hospital admission.

Testosterone and cardiovascular health

From a recent review:

Testosterone (T) has a number of important effects on the cardiovascular system. In men, T levels begin to decrease after age 40, and this decrease has been associated with an increase in all-cause mortality and cardiovascular (CV) risk. Low T levels in men may increase their risk of developing coronary artery disease (CAD), metabolic syndrome, and type 2 diabetes. Reduced T levels in men with congestive heart failure (CHF) portends a poor prognosis and is associated with increased mortality. Studies have reported a reduced CV risk with higher endogenous T concentration, improvement of known CV risk factors with T therapy, and reduced mortality in T-deficient men who underwent T replacement therapy versus untreated men. Testosterone replacement therapy (TRT) has been shown to improve myocardial ischemia in men with CAD, improve exercise capacity in patients with CHF, and improve serum glucose levels, HbA1c, and insulin resistance in men with diabetes and prediabetes. There are no large long-term, placebo-controlled, randomized clinical trials to provide definitive conclusions about TRT and CV risk. However, there currently is no credible evidence that T therapy increases CV risk and substantial evidence that it does not. In fact, existing data suggests that T therapy may offer CV benefits to men.

Septic encephalopathy

Free full text review.

Should we reinvent the physical exam?

Peter Pronovost thinks so.

Instead, maybe we should just do a decent job of teaching the one we now have.

A single ectopic beat on a 12 lead ECG is an important predictor

From a large database:

Clinical Perspective

What Is New?

Among participants in 2 large, community‐based cohort studies, the presence of a premature atrial contraction detected from a single, standard 12‐lead ECG predicted a statistically significant elevated risk of both incident atrial fibrillation and death.

Similarly, a premature ventricular contraction from a single, standard ECG predicted statistically significant increased risks of incident heart failure, decline in left ventricular ejection fraction, and death.

What Are the Clinical Implications?

In combination with other risk markers, ectopy on a single, standard 12‐lead ECG may provide valuable information regarding an individual's cardiovascular risk and serve as a broadly available tool for the prediction and prevention of atrial fibrillation, heart failure, and death.

Reducing blood culture contamination with a special collection device

Yes please:

Background.

Blood culture contamination is a clinically significant problem that results in patient harm and excess cost.

Methods.

In a prospective, controlled trial at an academic center Emergency Department, a device that diverts and sequesters the initial 1.5–2 mL portion of blood (which presumably carries contaminating skin cells and microbes) was tested against standard phlebotomy procedures in patients requiring blood cultures due to clinical suspicion of serious infection.

Results.

In sum, 971 subjects granted informed consent and were enrolled resulting in 904 nonduplicative subjects with 1808 blood cultures. Blood culture contamination was significantly reduced through use of the initial specimen diversion device™ (ISDD) compared to standard procedure: (2/904 [0.22%] ISDD vs 16/904 [1.78%] standard practice, P = .001). Sensitivity was not compromised: true bacteremia was noted in 65/904 (7.2%) ISDD vs 69/904 (7.6%) standard procedure, P = .41. No needlestick injuries or potential bloodborne pathogen exposures were reported. The monthly rate of blood culture contamination for all nurse-drawn and phlebotomist-drawn blood cultures was modeled using Poisson regression to compare the 12-month intervention period to the 6 month before and after periods. Phlebotomists (used the ISDD) experienced a significant decrease in blood culture contamination while the nurses (did not use the ISDD) did not. In sum, 73% of phlebotomists completed a post-study anonymous survey and widespread user satisfaction was noted.

Conclusions.

Use of the ISDD was associated with a significant decrease in blood culture contamination in patients undergoing blood cultures in an Emergency Department setting.

RALES disease

An emerging iatrogenic disease.

P wave indices and risk of ischemic stroke

From a recent paper:

Conclusions—P-wave terminal force in lead V1, P-wave duration, and maximum P-wave area are useful electrocardiographic markers that can be used to stratify the risk of incident ischemic stroke.

Spontaneous pneumothorax (apparent primary spontaneous pneumothorax) may be the first clue to certain cystic lung diseases

From a recent review:

Abstract:

Purpose of review: Diffuse cystic lung diseases (DCLDs) are a heterogeneous group of disorders with varying pathophysiologic mechanisms that are characterized by the presence of air-filled lung cysts. These cysts are prone to rupture, leading to the development of recurrent spontaneous pneumothoraces. In this article, we review the epidemiology, clinical features, and management DCLD-associated spontaneous pneumothorax, with a focus on lymphangioleiomyomatosis, Birt–Hogg–Dubé syndrome, and pulmonary Langerhans cell histiocytosis.

Recent findings: DCLDs are responsible for approximately 10% of apparent primary spontaneous pneumothoraces. Computed tomography screening for DCLDs (Birt–Hogg–Dubé syndrome, lymphangioleiomyomatosis, and pulmonary Langerhans cell histiocytosis) following the first spontaneous pneumothorax has recently been shown to be cost-effective and can help facilitate early diagnosis of the underlying disorders. Patients with DCLD-associated spontaneous pneumothorax have a very high rate of recurrence, and thus pleurodesis should be considered following the first episode of spontaneous pneumothorax in these patients, rather than waiting for a recurrent episode. Prior pleurodesis is not a contraindication to future lung transplant.

Summary: Although DCLDs are uncommon, spontaneous pneumothorax is often the sentinel event that provides an opportunity for diagnosis. By understanding the burden and implications of pneumothoraces in DCLDs, clinicians can facilitate early diagnosis and appropriate management of the underlying disorders.

Pseudo subarachnoid hemorrhage in post anoxic brain injury

Something to be aware of.

Emerging long term risks of proton pump inhibitors

From a recent review:

First introduced in 1989, proton pump inhibitors (PPIs) are among the most widely utilized medications worldwide, both in the ambulatory and inpatient clinical settings. The PPIs are currently approved by the US Food and Drug Administration for the management of a variety of gastrointestinal disorders including symptomatic peptic ulcer disease, gastroesophageal reflux disease, and nonulcer dyspepsia as well as for prevention of gastrointestinal bleeding in patients receiving antiplatelet therapy. PPIs inhibit gastric acid secretion, and the most commonly associated adverse effects include abdominal pain, diarrhea, and headache. Although PPIs have had an encouraging safety profile, recent studies regarding the long-term use of PPI medications have noted potential adverse effects, including risk of fractures, pneumonia, Clostridium difficile diarrhea, hypomagnesemia, vitamin B12 deficiency, chronic kidney disease, and dementia. These emerging data have led to subsequent investigations to assess these potential risks in patients receiving long-term PPI therapy. However, most of the published evidence is inadequate to establish a definite association between PPI use and the risk for development of serious adverse effects. Hence, when clinically indicated, PPIs can be prescribed at the lowest effective dose for symptom control.

Some medical axioms

From Joseph Alpert.

Early arterial ischemic events after VTE in cancer patients

From a recent report in AJM:

•Arterial events are a major cause of death in cancer patients with venous thrombosis.

•Arterial events occur early after venous thrombosis in cancer patients.

•The risk of arterial events should be considered in this clinical setting.

Abstract

Background

Venous thromboembolism is common in patients with malignancies, affecting up to 10% of this patient population. The association between arterial ischemic events and venous thromboembolism also has been established. However, the influence of arterial ischemic events on outcomes in cancer patients with venous thromboembolism has not been fully determined.

Methods

The current study analyzed clinical characteristics, time course, risk factors, incidence and severity of venous thromboembolism recurrences, arterial ischemic events and major bleeding in 5717 patients with active cancer and venous thromboembolism recruited into RIETE (multi-center prospective registry of patients with objectively confirmed venous thromboembolism).

Results

During the anticoagulation course (median 7.3 months), 499 (8.7%) patients developed venous thromboembolism recurrences, 63 (1.1%) developed arterial events, and 346 (6.1%) suffered from major bleeding. Overall, major bleeding and arterial events appeared earlier (median 35 and 36 days, respectively) than venous thromboembolism recurrences (median 97 days). Thirty-day mortality rates after each event were: 20% after recurrent pulmonary embolism, 13% after recurrent deep vein thrombosis, 41% after major bleeding, 40% after myocardial infarction, 64% after ischemic stroke, and 83% after lower limb amputation. Bleeding was the leading cause of death (67 fatal bleeds), whereas cumulative mortality due to arterial ischemic events (n = 27) was similar to that related to pulmonary embolism recurrences (n = 26).

Conclusions

In this study, arterial ischemic events and major bleeding appeared early after venous thromboembolism in patients with active cancer and were among frequent causes of their deaths. The risk and severity of arterial events need to be considered in this clinical setting.

ARDS: are we making a dent?

An analysis of ARDSnet trials shows declining mortality since 1996:

Objectives: There has been multiple advances in the management of acute respiratory distress syndrome, but the temporal trends in acute respiratory distress syndrome–related mortality are not well known. This study aimed to investigate the trends in mortality in acute respiratory distress syndrome patients over time and to explore the roles of daily fluid balance and ventilation variables in those patients.

Design: Secondary analysis of randomized controlled trials conducted by the Acute Respiratory Distress Syndrome Network from 1996 to 2013.

Setting: Multicenter study involving Acute Respiratory Distress Syndrome Network trials.

Patients: Patients with acute respiratory distress syndrome.

Interventions: None.

Measures and Main Results: Individual patient data from 5,159 acute respiratory distress syndrome patients (excluding the Late Steroid Rescue Study trial) were enrolled in this study. The crude mortality rate decreased from 35.4% (95% CI, 29.9–40.8%) in 1996 to 28.3% (95% CI, 22.0–34.7%) in 2013. By adjusting for the baseline Acute Physiology and Chronic Health Evaluation III, age, ICU type, and admission resource, patients enrolled from 2005 to 2010 (odds ratio, 0.61; 95% CI, 0.50–0.74) and those enrolled after 2010 (odds ratio, 0.73; 95% CI, 0.58–0.92) were associated with lower risk of death as compared to those enrolled before 2000. The effect of year on mortality decline disappeared after adjustment for daily fluid balance, positive end-expiratory pressure, tidal volume, and plateau pressure. There were significant trends of declines in daily fluid balance, tidal volume, and plateau pressure and an increase in positive end-expiratory pressure over the 17 years.

Conclusions: Our study shows an improvement in the acute respiratory distress syndrome-related mortality rate in the critically ill patients enrolled in the Acute Respiratory Distress Syndrome Network trials. The effect was probably mediated via decreased tidal volume, plateau pressure, and daily fluid balance and increased positive end-expiratory pressure.

Amp-C beta lactamase producing organisms

From a recent review:

BACKGROUND:

Enterobacterales are among the most common causes of bacterial infections in the community and among hospitalized patients, and multidrug-resistant (MDR) strains have emerged as a major threat to human health. Resistance to third-generation cephalosporins is typical of MDRs, being mainly due to the production of extended spectrum β-lactamases or AmpC-type β-lactamases.

OBJECTIVE:

The objective of this paper is to review the epidemiological impact, diagnostic issues and treatment options with AmpC producers.

FINDINGS:

AmpC enzymes encoded by resident chromosomal genes (cAmpCs) are produced by some species (e.g., Enterobacter spp., Citrobacter freundii, Serratia marcescens), while plasmid-encoded AmpCs (pAmpCs) can be encountered also in species that normally do not produce cAmpCs (e.g., Salmonella enterica, Proteus mirabilis, Klebsiella pneumoniae and Klebsiella oxytoca) or produce them at negligible levels (e.g., Escherichia coli). Production of AmpCs can be either inducible or constitutive, resulting in different resistance phenotypes. Strains producing cAmpCs in an inducible manner (e.g., Enterobacter spp.) usually appear susceptible to third-generation cephalosporins, which are poor inducers, but can easily yield mutants constitutively producing the enzyme which are resistant to these drugs (which are good substrates), resulting in treatment failures. pAmpCs are usually constitutively expressed. Production of pAmpCs is common in community-acquired infections, while cAmpC producers are mainly involved in healthcare-associated infections.

CONCLUSIONS:

To date, there is no conclusive evidence about the most appropriate treatment for AmpC-producing Enterobacterales. Carbapenems are often the preferred option, especially for severe infections in which adequate source control is not achieved, but cefepime is also supported by substantial clinical evidences as an effective carbapenem-sparing option.

Review of motor neuron disease

With ALS as a prototype.

Autoimmune thyroid disease

Free full text review. From the conclusion:

The management of autoimmune thyroid disease continues to be revised by new research which includes the identification of new entities, such as IgG4-related thyroid disease and new drug-induced forms of thyroid disease; the development of novel small molecules capable of influencing mechanisms of autoimmunity; and more detailed knowledge of the risks versus benefits of thyroxine therapy in subclinical hypothyroidism.

The relationship between atrial fibrillation and dementia

Reviewed in the green journal. It is unclear the extent to which it may be driven by factors other than stroke.

Acute exacerbation of IPF

Free full text review.

Adrenal crisis

Nuts, bolts and a lot of pearls here.

Trends in the use of ACLS drugs

Here are some findings from a recent study:

Objectives: Clinical providers have access to a number of pharmacologic agents during in-hospital cardiac arrest. Few studies have explored medication administration patterns during in-hospital cardiac arrest. Herein, we examine trends in use of pharmacologic interventions during in-hospital cardiac arrest both over time and with respect to the American Heart Association Advanced Cardiac Life Support guideline updates.

Design: Observational cohort study.

Setting: Hospitals contributing data to the American Heart Association Get With The Guidelines–Resuscitation database between 2001 and 2016.

Patients: Adult in-hospital cardiac arrest patients.

Interventions: The percentage of patients receiving epinephrine, vasopressin, amiodarone, lidocaine, atropine, bicarbonate, calcium, magnesium, and dextrose each year were calculated in patients with shockable and nonshockable initial rhythms. Hierarchical multivariable logistic regression was used to determine the annual adjusted odds of medication administration. An interrupted time series analysis was performed to assess change in atropine use after the 2010 American Heart Association guideline update.

Measurements and Main Results: A total of 268,031 index in-hospital cardiac arrests were included. As compared to 2001, the adjusted odds ratio of receiving each medication in 2016 were epinephrine (adjusted odds ratio, 1.5; 95% CI, 1.3–1.8), vasopressin (adjusted odds ratio, 1.5; 95% CI, 1.1–2.1), amiodarone (adjusted odds ratio, 3.4; 95% CI, 2.9–4.0), lidocaine (adjusted odds ratio, 0.2; 95% CI, 0.2–0.2), atropine (adjusted odds ratio, 0.07; 95% CI, 0.06–0.08), bicarbonate (adjusted odds ratio, 2.0; 95% CI, 1.8–2.3), calcium (adjusted odds ratio, 2.0; 95% CI, 1.7–2.3), magnesium (adjusted odds ratio, 2.2; 95% CI, 1.9–2.7; p less than 0.0001), and dextrose (adjusted odds ratio, 2.8; 95% CI, 2.3–3.4). Following the 2010 American Heart Association guideline update, there was a downward step change in the intercept and slope change in atropine use (p less than 0.0001).

Conclusions: Prescribing patterns during in-hospital cardiac arrest have changed significantly over time. Changes to American Heart Association Advanced Cardiac Life Support guidelines have had a rapid and substantial effect on the use of a number of commonly used in-hospital cardiac arrest medications.

Note the increased usage of bicarb and calcium. These are niche agents which are critically important in limited situations but have no place in the routine management of arrest. It is concerning that their use has increased despite being removed from ACLS protocols decades ago with a lack of high level evidence of benefit, possible evidence of harm, and the current bicarb shortage.

Effect of angiotensin II in patients with vasodilatory (mainly septic) shock requiring renal replacement therapy

From a recent post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial published in Critical Care Medicine:

Objective: Acute kidney injury requiring renal replacement therapy in severe vasodilatory shock is associated with an unfavorable prognosis. Angiotensin II treatment may help these patients by potentially restoring renal function without decreasing intrarenal oxygenation. We analyzed the impact of angiotensin II on the outcomes of acute kidney injury requiring renal replacement therapy.

Design: Post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial.

Setting: ICUs.

Patients: Patients with acute kidney injury treated with renal replacement therapy at initiation of angiotensin II or placebo (n = 45 and n = 60, respectively).

Interventions: IV angiotensin II or placebo.

Measurements and Main Results: Primary end point: survival through day 28; secondary outcomes included renal recovery through day 7 and increase in mean arterial pressure from baseline of greater than or equal to 10 mm Hg or increase to greater than or equal to 75 mm Hg at hour 3. Survival rates through day 28 were 53% (95% CI, 38%–67%) and 30% (95% CI, 19%–41%) in patients treated with angiotensin II and placebo (p = 0.012), respectively. By day 7, 38% (95% CI, 25%–54%) of angiotensin II patients discontinued RRT versus 15% (95% CI, 8%–27%) placebo (p = 0.007). Mean arterial pressure response was achieved in 53% (95% CI, 38%–68%) and 22% (95% CI, 12%–34%) of patients treated with angiotensin II and placebo (p = 0.001), respectively.

Conclusions: In patients with acute kidney injury requiring renal replacement therapy at study drug initiation, 28-day survival and mean arterial pressure response were higher, and rate of renal replacement therapy liberation was greater in the angiotensin II group versus the placebo group. These findings suggest that patients with vasodilatory shock and acute kidney injury requiring renal replacement therapy may preferentially benefit from angiotensin II.

Procalcitonin monitoring can help shorten the duration of antibiotic therapy in pneumonia

From a recent review:

Abstract:

Purpose of review: Increasing antimicrobial resistance is a worldwide phenomenon that is threatening public health. Lower respiratory infections are one of the leading causes of morbidity that contribute to antibiotic consumption and thus the emergence of multidrug-resistant microbial strains. The goal of shortening antibiotic regimens’ duration in common bacterial infections has been prioritized by antimicrobial stewardship programs as an action against this problem.

Recent findings: Data coming from randomized controlled trials, meta-analyses, and systematic reviews support the shortening of antimicrobial regimens in community-acquired, hospital-acquired, and ventilator-associated pneumonia. Short schedules have been proven at least as effective as long ones in terms of antimicrobial-free days and clinical cure. Procalcitonin-based algorithms have been validated as well tolerated and cost-effective tools for the duration of pneumonia therapy reduction.

Summary: Shortening the duration of antibiotic regimens in pneumonia seems a reasonable strategy for reducing selective pressure driving antimicrobial resistance and costs provided that clinical cure is guaranteed. Procalcitonin-based protocols have been proven essentially helpful in this direction.

Can procalcitonin help predict the microbiology of community acquired pneumonia?

From a recent study:

Abstract

Background.

Recent trials suggest procalcitonin-based guidelines can reduce antibiotic use for respiratory infections. However, the accuracy of procalcitonin to discriminate between viral and bacterial pneumonia requires further dissection.

Methods.

We evaluated the association between serum procalcitonin concentration at hospital admission with pathogens detected in a multicenter prospective surveillance study of adults hospitalized with community-acquired pneumonia. Systematic pathogen testing included cultures, serology, urine antigen tests, and molecular detection. Accuracy of procalcitonin to discriminate between viral and bacterial pathogens was calculated.

Results.

Among 1735 patients, pathogens were identified in 645 (37%), including 169 (10%) with typical bacteria, 67 (4%) with atypical bacteria, and 409 (24%) with viruses only. Median procalcitonin concentration was lower with viral pathogens (0.09 ng/mL; interquartile range [IQR], less than 0.05–0.54 ng/mL) than atypical bacteria (0.20 ng/mL; IQR, less than 0.05–0.87 ng/mL; P = .05), and typical bacteria (2.5 ng/mL; IQR, 0.29–12.2 ng/mL; P less than .01). Procalcitonin discriminated bacterial pathogens, including typical and atypical bacteria, from viral pathogens with an area under the receiver operating characteristic (ROC) curve of 0.73 (95% confidence interval [CI], .69–.77). A procalcitonin threshold of 0.1 ng/mL resulted in 80.9% (95% CI, 75.3%–85.7%) sensitivity and 51.6% (95% CI, 46.6%–56.5%) specificity for identification of any bacterial pathogen. Procalcitonin discriminated between typical bacteria and the combined group of viruses and atypical bacteria with an area under the ROC curve of 0.79 (95% CI, .75–.82).

Conclusions.

No procalcitonin threshold perfectly discriminated between viral and bacterial pathogens, but higher procalcitonin strongly correlated with increased probability of bacterial pathogens, particularly typical bacteria.

Renin-aldosterone profiling for all hypertensives? Have we come full circle?

Decades ago John Laragh popularized renin profiling for the evaluation of hypertensive patients. But due to limited availability of testing in community practice and a shift in the way population based research was applied to the treatment of hypertension it fell out of favor. More recently interest has resurfaced. In a recent issue of JACC there is a paper on the prevalence and clinical characteristics of primary aldosteronism. From the paper:

Background Despite being widely recognized as the most common form of secondary hypertension, among the general hypertensive population the true prevalence of primary aldosteronism (PA) and its main subtypes, aldosterone-producing adenoma (APA) and bilateral adrenal hyperplasia (BAH), remains a matter of debate.

Objectives This study sought to determine the prevalence and clinical phenotype of PA in a large cohort of unselected patients with hypertension, consecutively referred to our hypertension unit, by 19 general practitioners from Torino, Italy.

Methods Following withdrawal from all interfering medications, patients were screened for PA using the ratio of serum aldosterone to plasma renin activity. PA was diagnosed according to Endocrine Society guidelines. The diagnosis was confirmed or excluded by an intravenous saline infusion test or captopril challenge test and subtype differentiation was performed by adrenal computed tomography scanning and adrenal vein sampling, using strict criteria to define successful cannulation and lateralization of aldosterone production.

Results A total of 1,672 primary care patients with hypertension (569 newly diagnosed and 1,103 patients already diagnosed with arterial hypertension) were included in the study. A total of 99 patients (5.9%) were diagnosed with PA and conclusive subtype differentiation by adrenal vein sampling was made in 91 patients (27 patients with an APA and 64 patients with BAH). The overall prevalence of PA increased with the severity of hypertension, from 3.9% in stage 1 hypertension to 11.8% in stage 3 hypertension. Patients with PA more frequently displayed target organ damage and cardiovascular events compared with those without PA, independent of confounding variables.

Conclusions Our results demonstrated that PA is a frequent cause of secondary hypertension, even in the general population of patients with hypertension, and indicates that most of these patients should be screened for PA.

An editorial in the same issue advocates for screening of all hypertensives.

There were some eye opening findings. Of the target organ complications cited above, LVH was seen in 54% of patients with PA vs 32% of those with essential hypertension (EH), microalbuminuria in 27% with PA vs 13% with EH and cardiovascular events in 15% with PA vs 6% with EH. Serum potassium was not a useful marker, as hypokalemia was seen in only 29% of those with PA.

Screening is not that difficult but what if the patient tests positive? That would lead to a lot of CT scans and invasive adrenal vein samplings. As the speaker in the audio file said, it’s something to think about the next time a patient with hypertension comes into your office.

PPI use may be associated with better heart failure outcomes

From a recently published study:

Abstract

Background It has been recently reported that histamine H2 receptor antagonists (H2RAs) are associated with impairment of ventricular remodeling and incident heart failure. In addition, favorable pleiotropic effects and adverse effects of proton pump inhibitors (PPIs) on cardiovascular disease have also been reported. We examined the associations of acid suppressive therapy using H2RAs or PPIs with cardiac mortality in patients with heart failure.

Methods and Results In total, 1191 consecutive heart failure patients were divided into 3 groups: a non–acid suppressive therapy group (n=363), an H2RA group (n=164), and a PPI group (n=664). In the follow‐up period (mean 995 days), 169 cardiac deaths occurred. In the Kaplan–Meier analysis, cardiac mortality was significantly lower in the PPI group than in the H2RA and non–acid suppressive therapy groups (11.0% versus 21.3% and 16.8%, respectively; log‐rank P=0.004). In the multivariable Cox proportional hazards analysis, use of PPIs, but not H2RAs, was found to be an independent predictor of cardiac mortality (PPIs: hazard ratio 0.488, P=0.002; H2RAs: hazard ratio 0.855, P=0.579). The propensity‐matched 1:1 cohort was assessed based on propensity score (H2RAs, n=164; PPIs, n=164). Cardiac mortality was significantly lower in the PPI group than in the H2RA group in the postmatched cohort (log‐rank P=0.025). In the Cox proportional hazards analysis, the use of PPIs was a predictor of cardiac mortality in the postmatched cohort (hazard ratio 0.528, P=0.028).

Conclusions PPIs may be associated with better outcome in patients with heart failure.

Sherlock Holmes and clinical skills

Here’s an essay in the green journal on the value of the history and physical examination.

Paget’s disease of bone

From a recent review article:

The most likely etiology is a slow paramyxoviral infection in genetically susceptible individuals; however, the exact cause is unknown. Enhanced bone resorption due to an increased activity of osteoclasts recruits numerous osteoblasts to resorption sites, with large quantities of new bone matrix produced as a result. The accelerated bone resorption and formation are not as closely coupled as in a healthy bone; a disorganized bone tissue is formed. Many patients are asymptomatic; rising serum alkaline phosphatase or incidental finding of characteristic radiographic lesions are often the only diagnostic clues. Common clinical manifestations include bone pain, bowing of long bones, enlarged skull, and hearing loss. An elevated serum alkaline phosphatase level correlates with the disease activity. The diagnosis is confirmed by characteristic radiographic findings and by nuclear scintigraphy of the bone (the most sensitive test).

Impella may gradually replace the balloon pump in cardiogenic shock

Here’s a report from the American Journal of Medicine.

More uncritical praise for the hospitalist movement

This time it comes from The American Journal of Medicine.  From the recent narrative review article:

Multiple studies have shown that patients managed by a hospitalist have a shorter length of stay and lower hospital costs than those managed by other physicians.1, 3,6, 7

The reduced length of stay and reduced hospitalization costs are sufficient to strongly encourage community and teaching hospital directors to adopt and support the hospitalist model.

This is by no means proven.  Arguably the best and largest study examining this issue was negative.  It was presented at the hospitalist national meeting in 2005.  The researchers were leaders in the hospitalist movement.  The study was never published.  In fact, it was buried to such a degree that I had to go to the Internet Archive to find it.  You can access it at page 25 of this link.

Update: Since I composed this post, the link immediately above has gone bad. It’s been scrubbed from the Wayback Machine. I wasn’t aware that was possible but found out today that if you want something removed it’s easy enough to do, though requiring deliberate effort, as described here. Things don’t just disappear from the archive so I can only conclude that someone wanted it removed.

The study, though reported in The Hospitalist magazine, was never published in a Medline indexed journal, thus biasing every systemic review and meta-analysis on the hospitalist model published since then.

Fortunately the study received quite a bit of attention in the blogosphere at the time. Dr. Robert Centor, the author of DB’s Medical Rants, blogged about it and reproduced the study findings. Here they are, from his post:

Background: Several studies suggest that hospitalists can improve costs or outcomes in academic medical centers, but almost all of these studies have nonrandom assignment of patients to hospitalists, and no multi¬center studies exist. We studied patients assigned to hospitalist or non-hospitalist physicians based only on day of admission to determine the effects of hospitalists on outcomes and costs in 6 academic medical centers.

Methods: From July 2001 to June 2003, 31,891 general medicine inpatients were assigned to hospitalist or non-hospitalist physicians according to a predetermined daily call schedule. Patient interviews at admission and 1 month after discharge and administrative data were used to study effects on outcomes and costs.

Results: Twelve thousand and onepatients were cared for by hospitalists and 19,890 by non-hospitalists. There were no statistically significant differences in age, race, gender, Charlson Index, or distribution of primary diagnosis be¬tween the 2 groups. There were no statistically significant differences in in-hospital mortality, 30-day readmission and emergency room use, 30-day self-reported health status, or patient satisfaction. Mortality data up to 1 year after admission are pending. Average length of stay was 0.05 days shorter for hospitalist patients but this difference was not statistically significant. Costs were also similar between the groups. Individual center analyses had large confidence intervals on outcomes and costs and failed to show statistically significant effects on any measure of outcomes or costs except for 1 of the larger centers, which had lower length of stay and costs for hospitalists.

Conclusions: Hospitalists had small effects on selected outcome measures available to date, but did not produce the large resource savings that had been suggested by some earlier studies. The effectiveness of hospitalists appeared to vary by site, but was difficult to assess due to limited statistical power for site-specific analyses. Understanding the factors, such as physician experience, that may influence the effectiveness of hospitalists is important for maximizing the efficacy of hospitalist programs, because effects on outcomes may be small, vary by site, and be difficult to distinguish from chance in a specific clinical setting.

Clinical Cases and Images and California Medicine Man also reported it.

Doctors: shut up!

Paul Hsieh wrote in Forbes:

Of course, doctors have the same free speech rights as any individuals, and are free to offer their thoughts on climate change or foreign policy like anyone else. But when medical organizations and medical journals start offering opinions outside their field of expertise, they simply harm their credibility and sound silly — or arrogant.

Read the entire article.  Two or three times.

The Fourth Universal Definition of Myocardial Infarction

Here’s a green journal summary by Joseph Alpert, one of the authors of the document and editor in chief of the green journal.  Free full text of the original document is here.

Health care team members’ perceptions and attitudes about emergency only hemodialysis (EOHD)

Concerns for what we today refer to as social justice seemed to dominate the responses in this small qualitative study.  

Annals article on EBM and machine learning makes huge category errors

From the beginning of the paper:

Machine learning (ML), which converts complex data into algorithms, challenges the traditional epidemiologic approach of evidence-based medicine (EBM). Here I outline the differences, strengths, and limitations of these 2 approaches and suggest areas of reconciliation.

Beginning in the 1970s, scientists extolled the virtues of EBM's hypothesis-driven, protocolized experiments involving well-defined populations and preselected exposure and outcome variables. Inferences were made using traditional biostatistics.

First, EBM wasn’t around in the 70’s.  It started, as a movement, in 1992.  Second, EBM is not a method of research.   It is, rather, a system of approaching the clinical care of individual patients.  One patient at a time.  The rest of the article is equally confusing.