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ACP HospitalistWeekly 9-2-09

Highlights

  • Caregivers don’t always want doctors' advice on life-support decisions, study finds

Evidence-based therapy

  • Paper summarizes latest evidence on antiplatelets and antithrombotics for ACS

Warfarin and atrial fibrillation

  • Benefits may outweigh risks for elderly AF patients on warfarin, study concludes
  • Warfarin lowers stroke risk in older AF patients but risk may rise in patients with ESRD

From ACP Internist

  • The next issue of ACP Internist is online and in your mailbox
  • Your thoughts exactly: town hall meetings on health reform

Cartoon caption contest

Physician editor: A. Scott Keller, FACP

Editorial note: ACP HospitalistWeekly will not be published next week due to the Labor Day holiday.


Highlights

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Caregivers don’t always want doctors' advice on life-support decisions, study finds

A new study challenges the commonly held notion that most caregivers of critically ill patients want to hear doctors’ opinions on life-support decisions.

The study, published in the Aug. 15 American Journal of Respiratory and Critical Care Medicine, prospectively recruited 169 surrogates from four ICUs and asked them to watch and respond to two videos depicting hypothetical conferences in which surrogates must decide whether to withdraw or continue life support. In one version, the doctor offers his opinion on a course of action while in the other version the doctor urges the family to make its own decision consistent with the patient’s values. Only 56% of surrogates preferred the version in which the doctor offers an opinion, while 42% preferred no recommendation and 2% had no preference.

Current guidelines recommend that physicians offer opinions routinely about whether to limit life support, the authors noted, but these new findings highlight the need for a different approach that stresses both the unique needs of individual surrogates and the physician’s ethical obligation to ensure that decisions are made in accordance with the patient’s values. They recommended that physicians first ask surrogates about whether they would like to hear an opinion and use any recommendation as a starting point for shared deliberations.

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Evidence-based therapy

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Paper summarizes latest evidence on antiplatelets and antithrombotics for ACS

A new paper examines the safety, efficacy and timing of antithrombotics in acute coronary syndromes, highlights outstanding controversies and looks at the potential roles of the most promising new drugs in late-stage development.

The analysis, published online and in the Sept. 8 Journal of the American College of Cardiology, summarizes the evidence regarding the use of antiplatelets and anticoagulants for acute coronary syndromes (ACS). Despite great advances in antithrombotic therapies, high risks remain connected with patient comorbidities, drug combinations, dosing adjustments and complex care environments, the authors said. The paper includes the following observations:

Antiplatelets

  • Data support the use of intravenous glycoprotein IIb/IIIa inhibitors (GPIs) in the setting of moderate- or high-risk non-ST-segment elevation ACS (NSTE-ACS), especially in the case of early invasive strategy. Patients presenting with ST-segment elevation myocardial infarction (STEMI) who are undergoing percutaneous coronary intervention (PCI) also may benefit. For low-risk ACS, GPIs are potentially harmful in troponin-negative patients under conservative management or those with elevated bleeding risk.
  • Clopidogrel plus aspirin appears beneficial and safe in patients with STEMI, although there are no safety data with a loading dose for elderly patients receiving fibrinolytics or in patients with STEMI managed without reperfusion therapy.
  • The benefits of early pre-loading with clopidogrel within five days of surgery appear to outweigh the risks of perioperative bleeding.
  • Prasugrel has a protective effect in ACS patients and may reduce stent thrombosis, but it may increase major bleeding in patients with a history of stroke or transient ischemic attack, patients age 75 or older and those weighing less than 60 kg.

Anticoagulants

  • Low-molecular-weight heparin (LMWH) has proven superior to short-term unfractionated heparin (UFH) in conservative management of patients with NSTE-ACS, but questions remain about the use of LMWH in certain settings, including an early invasive strategy, rapid transitions to catheterization lab, procedural anticoagulation and in conjunction with fibrinolytic therapy for patients with STEMI.
  • Adding UFH to enoxaparin in an uncontrolled fashion may result in increased bleeding complications.
  • Continued in-hospital administration of enoxaparin may provide substantial additional benefit in patients with STEMI.
  • Overall, LMWH appears to be a viable option across a wide spectrum of patients presenting with ACS, suggesting that it should be investigated further for potential use in other settings such as primary PCI for acute MI.
  • The factor Xa inhibitor fondaparinux appears to reduce the risk of bleeding and lowers long-term morbidity and mortality compared with enoxaparin in NSTE-ACS, although there were more catheter-related thrombi. However, fondaparinux appears to be associated with a risk of harm (increased rate of coronary complications) in STEMI patients treated with primary PCI.
  • Promising drugs in the pipeline include novel anticoagulants that inhibit propagation of coagulation by targeting factor IXa, Xa or their cofactors. These agents are based upon aptamer technology, which addresses control and reversibility in acute care settings and could play a crucial role during and after cardiopulmonary bypass for coronary surgery and other situations where bleeding occurs. However, the authors noted that long-term investments are needed to gain clinical and regulatory acceptance of these new drugs.

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Warfarin and atrial fibrillation

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Benefits may outweigh risks for elderly AF patients on warfarin, study concludes

The risk of major bleeding is higher in elderly patients than in younger patients with atrial fibrillation taking warfarin, but careful management can keep the risks acceptably low, a recent study concluded.

In the prospective observational study, researchers looked at 783 patients with AF on warfarin who spent (respectively) a median of 14%, 71% and 15% of time below, within and above the intended therapeutic range. There was no difference in treatment quality between patients younger than or older than 80 years, but bleeding risk was higher in patients with a history of previous cerebral ischemic event and patients age 80 or older. The study appears in the Journal of the American College of Cardiology.

The findings indicate that the absolute risk of major bleeding in patients aged 80 or older is acceptably low (2.5 × 100 patient/years), the authors concluded. While a previous study found a fivefold increase in major bleeding among elderly AF patients, that study included more patients with coronary artery disease and concomitant use of aspirin, they said.

The authors noted that using computer-assisted systems for dose adjustment may have helped achieve the low bleeding rates found in the study. Overall, the findings suggest that elderly patients can benefit from warfarin therapy provided that good-quality anticoagulation can be obtained based on ranges set by the international normalized ratio.

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Warfarin lowers stroke risk in older AF patients but risk may rise in patients with ESRD

Elderly adults at high risk for stroke benefit most from the use of warfarin for atrial fibrillation, according to one study, but another study warns that warfarin may increase the risk of stroke in atrial fibrillation patients on hemodialysis.

In the first study, published in the Sept. 1 Annals of Internal Medicine, researchers studied six-year rates of ischemic stroke and intracranial hemorrhage in more than 13,000 adults with nonvalvular atrial fibrillation (AF). The adjusted net clinical benefit of warfarin overall was 0.68% per year and was greatest among patients who had a history of ischemic stroke or were 85 years or older. The authors concluded that risk assessment for prescribing anticoagulants in AF patients should incorporate risks for both thromboembolism and intracranial hemorrhage.

The authors noted that patients with the highest CHADS-2 scores (one point for each of congestive heart failure, hypertension, age and diabetes and two points for stroke) benefited most from anticoagulation while those in the lowest-risk categories showed little benefit, findings that validate recent guidelines restricting recommendations for anticoagulant therapy to patients with a CHADS-2 score of two or more. They concluded that their findings highlight the potentially significant net clinical benefit of warfarin anticoagulation for patients with AF at high risk for ischemic strokes.

In the second study, published in the Journal of the American Society of Nephrology, researchers studied the association between the use of warfarin, clopidogrel or aspirin and new stroke, mortality and hospitalization in a retrospective cohort of 1,671 hemodialysis patients with pre-existing AF. After an average follow-up of 1.6 years, warfarin use (compared with non-use) was associated with a significantly increased risk of new stroke (both ischemic and hemorrhagic), but not of all-cause mortality or hospitalization. The risk was greatest among patients who did not receive international normalized ratio monitoring in the first 90 days of dialysis. Clopidogrel or aspirin use was not associated with an increased risk of new stroke.

The findings, combined with the results of a previous study that found increased mortality risk with anticoagulation use in end-stage renal disease (ESRD) patients, should raise concern about the use of warfarin in dialysis patients, the authors noted, but they cautioned that large randomized trials are needed before changing recommendations. For now, they said, physicians should conduct careful risk evaluations and ensure close monitoring of ESRD patients on warfarin to minimize risks of hemorrhagic complications.

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From ACP Internist

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The next issue of ACP Internist is online and in your mailbox

The next issue of ACP Internist is online, featuring stories on:

Guiding clinicians through GI diagnoses. ACP Internist wraps up highlights of Digestive Disease Week, including dyspepsia, weight loss and incontinence, as well as the latest about the risks of proton-pump inhibitors and antithrombotics.

MS confounds, calls for better coordinationMS confounds, calls for better coordination. Internists are closely involved in care for multiple sclerosis, from recognizing symptoms to preventing complications. As the first line of defense, primary care physicians can find reassurance in guidance from a recent consensus paper on differential diagnosis.



Mindful medicine: Unmasking the patient’s hidden agenda. Something about a response of ‘so-so’ triggers Ian Gilson, FACP, to delve further into how a patient is feeling—and a potentially suicidal hidden agenda.

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Your thoughts exactly: town hall meetings on health reform

In August, members of Congress and the White House held town hall meetings to discuss health care reform. The meetings were sometimes productive but often contentious. Tell us: Were the meetings a success or a failure in making progress on the issue?

Also, Steven Weinberger, FACP, ACP Deputy Executive Vice President and Senior Vice President for Medical Education and Publishing, discusses "Health Care Reform: The Uncivil War Dividing America," in his monthly column for KevinMD.com.

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Cartoon caption contest

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And the winner is …

ACP HospitalistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Leigh Nathan, a fourth-year medical student at Temple University School of Medicine in Philadelphia, who will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 151 ballots online to choose the winning entry. Thanks to all who voted!

Sir, I said follow my finger, not swallow my finger
"Sir, I said follow my finger, not swallow my finger."

The runners up were:
"You still need to undress. I told you I wouldn't be able to feel your prostate from this end."
"This is a new treatment for excessive verbiage about health care reform."

ACP HospitalistWeekly's cartoon caption contest continues after the Labor Day holiday.

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ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. Please forward any comments or suggestions to acphospitalist@acponline.org.

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Copyright 2009 by the American College of Physicians.

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