Migraines and stroke, guidance for transcatheter aortic valve replacement, and more

In the News is a product of ACP Hospitalist Weekly, an e-newsletter provided every Wednesday by ACP Hospitalist.

Migraine may be linked to perioperative stroke, hospital readmission

History of migraine, especially migraine with aura, may be associated with increased stroke risk and risk for hospital readmission after surgery, according to a recent study.

Researchers performed a prospective hospital registry study at Massachusetts General Hospital in Boston and two satellite campuses from January 2007 to August 2014 to determine whether risk for perioperative ischemic stroke and subsequent increased hospital readmission rates are associated with migraine in surgical patients. The study's primary outcome was perioperative ischemic stroke within 30 days after surgery. Hospital readmission within 30 days of surgery was the secondary outcome, and postdischarge stroke and neuroanatomical stroke location were exploratory outcomes. The study results were published online by BMJ on Jan. 10.

A total of 124,558 patients who had surgery under general anesthesia and with mechanical ventilation were included in the study. Slightly over half (54.6%) were women, and the mean age was 52.6 years. Of these, 10,179 (8.2%) had any type of migraine diagnosis, 1,278 (12.6%) with aura and 8,901 (87.4%) without. Perioperative ischemic stroke occurred within 30 days of surgery in 771 patients (0.6%), with increased risk seen in patients with migraine versus those without (adjusted odds ratio, 1.75; 95% CI, 1.39 to 2.21). Migraine with aura was associated with higher risk compared to migraine without aura (adjusted odds ratio, 2.61 [95% CI, 1.59 to 4.29] versus 1.62 [95% CI, 1.26 to 2.09], respectively).

The researchers calculated a predicted absolute risk of 2.4 perioperative ischemic strokes for every 1,000 surgical patients and found that this risk was 4.3 for every 1,000 patients with migraine, 3.9 for every 1,000 patients with migraine but no aura, and 6.3 for every 1,000 patients with migraine and aura. Rate of readmission within 30 days of discharge was also higher in patients with migraine (adjusted odds ratio, 1.31; 95% CI, 1.22 to 1.41).

The authors noted that they based their classification of migraine and migraine with aura on ICD-9 codes in the hospitals' data registry and that some patients may have been misclassified. In addition, they pointed out that use of the available ICD-9 codes could have led to inclusion of patients who had the most severe symptoms of aura, possibly a subgroup at higher risk for stroke. However, they concluded that their results indicate that migraine, especially migraine with aura, should be included as a marker for increased ischemic stroke risk, including perioperatively.

They suggested that use of high-dose vasopressors during surgery and history of a possible right-to-left shunt might be modifiable risk factors in patients who have migraine with aura and said that close postoperative monitoring for early detection of stroke symptoms in high-risk patients is essential. Migraine should be included in assessment of perioperative risk in patients preparing for surgery, the authors suggested.

Guidance issued for decision making on transcatheter aortic valve replacement

The American College of Cardiology recently released an expert decision consensus pathway to help guide decision making about transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis.

The pathway is based on expert consensus and provides point-of-care checklists and algorithms about TAVR in four sections: preprocedure evaluation, imaging modalities and measurements, key issues in performing the procedure, and recommendations for patient follow-up.

The decision pathway stressed the need for shared decision making and patient education when determining whether TAVR should be performed and recommended that initial assessment include evaluation of symptoms of aortic stenosis, disease severity, and standard clinical data, in addition to major cardiovascular and noncardiovascular comorbid conditions. The clinical team should also review echocardiographic measures of aortic stenosis severity, confirm disease severity, and perform additional imaging as needed, the pathway said. Frailty and disability should also be considered, along with cognitive function and futility.

An included checklist for post-TAVR clinical management outlined the key steps to be taken immediately after the procedure, including waking from sedation, postprocedure monitoring, pain management, early mobilization, and discharge planning.

Patients should be extubated early and their mental status should be monitored, the checklist said. Telemetry and vital signs should be monitored according to hospital protocol, intake and output should be monitored, and routine labs should be done. The access site should also be monitored for bleeding, hematoma, or pseudoaneurysm, the checklist said.

When planning discharge, clinicians should resume the patient's preoperative medications, plan the discharge location, order an echocardiogram and electrocardiogram before discharge, and schedule postdischarge clinic visits, according to the checklist.

The full decision pathway was published Jan. 4 by the American College of Cardiology.

New pathway may rule out more patients, miss fewer MIs than guideline-approved pathway

An early rule-out pathway for myocardial infarction (MI) may rule out more patients on presentation and miss fewer index or recurrent MI cases than the rule-out pathway recommended by the European Society of Cardiology (ESC), according to a recent study.

Researchers compared the safety and efficacy of the ESC rule-out pathway (based exclusively on high-sensitivity cardiac troponin concentrations <99th percentile at presentation [16 ng/L for women and 34 ng/L for men], or at three hours if symptoms last less than six hours) and the new pathway, which incorporates lower cardiac troponin concentrations (risk-stratification threshold of 5 ng/L at presentation, with retesting at three hours if symptom onset is less than two hours from presentation or if ≥5 ng/L at presentation).

Patients with suspected acute coronary syndrome were recruited from the ED of a tertiary care hospital in Scotland into a sub-study of the High-Sensitivity Troponin in the Evaluation of patients with Acute Coronary Syndrome (High-STEACS) trial, where the pathway was developed. They evaluated the negative predictive value (NPV) of each pathway using a composite endpoint of index type 1 MI, or subsequent type 1 MI or cardiac death at 30 days.

Results were published online on Dec. 29, 2016, by Circulation and appear in the March 7 print issue.

In 1,218 patients, the adjudicated diagnosis was type 1 MI in 189 (15.5%), type 2 MI in 67 (5.5%), and myocardial injury in 26 (2.1%). At presentation, 216 patients had troponin concentrations above the 99th percentile: 145 (11.9%) with type 1 MI, 46 (3.8%) with type 2 MI, and 25 (2.1%) with myocardial injury. There were six subsequent type 1 MI and six cardiac deaths at 30 days.

The ESC pathway ruled out 342 patients (28.1%) at presentation and 961 patients (78.9%) by three hours. This approach missed 18 index type 1 MIs (four on presentation, 14 at three hours) and two subsequent MIs within 30 days (overall NPV, 97.9%; 95% CI, 96.9% to 98.7%). The sensitivity of this pathway was 89.3% (95% CI, 84.9% to 93.5%).

In comparison, the High-STEACS pathway ruled out 496 patients (40.7%) at presentation and 904 patients (74.2%) by three hours. This approach missed two index type 1 MIs at three hours and two subsequent MIs at 30 days (all events were also missed by the ESC pathway), for an overall NPV of 99.5% (95% CI, 99.0% to 99.9%). The sensitivity of this pathway was 97.7% (95% CI, 95.5% to 99.5%).

Limitations of the study include its observational design and the fact that true efficacy and safety of the High-STEACS pathway are unknown because no patients were discharged on the basis of pathway decisions, the study authors noted. Utilizing low cardiac troponin concentrations to risk-stratify patients “identifies more patients as low risk at presentation, and has a better overall negative predictive value than guideline approved pathways based solely on the 99th centile,” they wrote. “Implementation of this pathway has the potential to improve the efficiency and safety of early rule-out approaches for patients with suspected acute coronary syndrome.”

Study looks at frequency of ‘surprise’ medical bills

Twenty percent of inpatient admissions from the ED, 14% of outpatient visits to the ED, and 9% of elective inpatient admissions were linked to “surprise” medical bills in a recent study.

The study defined a surprise medical bill as “a bill from an out-of-network provider that was not expected by the patient or that came from an out-of-network provider not chosen by the patient.” Researchers used data from a nationwide claims database that tracks patients with employer-sponsored health insurance to measure the rate of such bills among those whose health plans offered incentives for using in-network clinicians. Data from 2007-2014 were considered.

Photo by Thinkstock
Photo by Thinkstock

Emergency cases were considered likely to lead to a surprise medical bill if they involved emergency care at an in-network hospital where the ED or other hospital physicians were out of network, if they involved an admission by an in-network ED at an in-network hospital but treatment by an out-of-network physician, and if they involved transportation by ambulance to an out-of-network hospital for emergency care. Elective inpatient admissions were considered likely to lead to a surprise medical bill if they involved an in-network hospital and primary care physician (or no primary care physician was identified in the database) but at least one other clinician or service that was out of network. The study results were published online in December 2016 by Health Affairs.

In 2014, the most recent year for which data were available, 20% of inpatient admissions from the ED, 14% of outpatient visits to the ED, and 9% of elective inpatient admissions were classified as likely to lead to surprise medical bills. This represented a decrease in all categories from 2007 (of approximately 28%, 18%, and 14%, respectively). Patients were more likely to get a surprise medical bill if they were older and if their diagnosis was medically complex. ED outpatient visits were less likely to result in a surprise medical bill than ED visits that led to an inpatient admission, which “suggests that the likelihood of receiving a surprise medical bill increases with the severity and complexity of a patient treatment episode,” the authors wrote. Likewise, inpatient admissions were more likely to lead to a surprise medical bill if length of stay was longer and involved more services and procedures. Physicians who were not based in the hospital were the most likely source of potential surprise bills.

The study authors noted that they could not determine whether patients expected to receive medical bills and could only look at conditions in which surprise bills were likely. However, they concluded that based on their results, patients who receive bills for out-of-network care are often surprised by them. They speculated that the decrease in rates of surprise bills over time may be related to increased employment of physicians by hospital systems or large group practices but said further research was needed in that area. They also noted that the finding of more surprise medical bills among patients admitted with more severe diagnoses was “troubling” because insurance is meant to provide more financial protection in such cases.

“Patients with employer-sponsored insurance can receive treatment from out-of-network providers in situations where they likely expect their care to be in network or they are unable to choose an in-network provider, which leads to surprise medical bills and possibly to unavoidable medical financial burdens,” the authors wrote. “More research is needed to better understand the factors that contribute to or could ameliorate this problem.”