POCUS for DVT, inpatient digoxin

Summaries from ACP Hospitalist Weekly.

POCUS can be used by hospitalists to rule out deep venous thrombosis in ward patients

Hospitalists effectively used point-of-care ultrasound (POCUS) to rule out deep venous thrombosis (DVT) in non-ICU patients, a recent study found.

Photo by Getty Images
Photo by Getty Images

The prospective cohort study enrolled a convenience sample from four tertiary care hospitals of hospitalized non-ICU patients for whom a DVT ultrasound was ordered. Hospitalists performed POCUS with a three-region compression protocol to look for DVT, and the results were compared with the corresponding formal vascular study interpreted by radiologists. The study was published by the Journal of General Internal Medicine on Aug. 6, 2019, and appeared in the October 2019 issue.

A total of 125 limbs from 73 patients were scanned, and DVT was found in eight (6.4%). This was a lower prevalence than expected. The sensitivity of POCUS for DVT was 100% (95% CI, 74% to 100%) and specificity was 95.8% (95% CI, 91% to 98%), with a positive predictive value of 61.5% (95% CI, 35% to 84%) and a negative predictive value of 100% (95% CI, 98% to 100%). The hospitalist-operated compression ultrasonography (HOCUS) was completed substantially faster than formal vascular studies; the median time from order to POCUS completion was 5.8 hours, compared to 11.5 hours from order until finalized radiology report (P=0.001).

This is the first study to look at POCUS for DVT diagnosis in non-ICU hospitalized patients, according to the study authors, and it “shows that hospitalists can be trained to competently perform POCUS with good sensitivity and excellent specificity.” The results suggest that a negative POCUS finding could rule out DVT in a hospitalized patient, although more research is needed to determine how to act on a positive POCUS, they said.

The authors noted that the participating hospitalists underwent only two hours of training and 10 practice scans on standardized patients. The study did have limitations, particularly its small sample size. The low DVT prevalence led to a low positive predictive value for POCUS, but the authors speculated that many of the false positives in the study would not have occurred in practice, where hospitalists could choose to do POCUS based on patients' pretest probability for DVT.

“Further study is needed to ensure generalizability of our findings, understand how to integrate this into a hospitalist's workflow, and consider how this approach might be shared with trainees,” they concluded.

Stopping digoxin after a heart failure exacerbation associated with risk of readmission

Stopping preadmission digoxin therapy was associated with worse outcomes among hospitalized older patients with heart failure with reduced ejection fraction (HFrEF) receiving guideline-directed medical therapies, a study found.

Researchers sought to determine the relationship between stopping digoxin and outcomes among hospitalized patients with heart failure and an ejection fraction of 45% or less. They studied 3,499 patients from the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry who were on digoxin at admission. Digoxin was discontinued before discharge in 721 patients, and researchers used propensity scores to match 698 of them with patients who continued taking digoxin. Results were published by JACC on July 29, 2019, and appeared in the August 2019 issue.

Four years after discharge, having stopped digoxin was associated with significantly higher risks of heart failure readmission (hazard ratio [HR], 1.21; 95% CI, 1.05 to 1.39; P=0.007), all-cause readmission (HR, 1.16; 95% CI, 1.04 to 1.31; P=0.010), and the combined endpoint of heart failure readmission or all-cause mortality (HR, 1.20; 95% CI, 1.07 to 1.34; P=0.002), but not all-cause mortality alone (HR, 1.09; 95% CI, 0.97 to 1.24; P=0.163). At six months and one year after discharge, stopping digoxin was associated with a significantly higher risk of all four outcomes. At 30 days, stopping digoxin was associated with higher risks of all-cause mortality (HR, 1.80; 95% CI, 1.26 to 2.57; P=0.001) and the combined endpoint (HR, 1.36; 95% CI, 1.09 to 1.71; P=0.007), but not heart failure readmission (HR, 1.19; 95% CI, 0.90 to 1.59; P=0.226) or all-cause readmission (HR, 1.03; 95% CI, 0.84 to 1.26; P=0.778).

The authors wrote, “Considering the recent decline in the use of digoxin, a drug known for its efficacy and effectiveness in reducing the risk of hospitalization, the findings of the current study are important because they suggest that in hospitalized patients with HFrEF receiving contemporary GDMT [guideline-directed medical therapies] including beta-blockers and MRAs [mineralocorticoid receptor antagonists], the discontinuation of digoxin therapy may be associated with worse post-discharge outcomes.”

An editorial noted that the medical community may have prematurely abandoned using digoxin for HFrEF. “If the clinician already believes that clinical outcomes can be improved with digoxin on the basis of previous studies, the current study reinforces that conviction in a relatively large patient cohort and long follow-up, albeit in a retrospective analysis from a nonrandomized prospective registry,” the editorial stated. “If the clinician is less convinced that digoxin is truly efficacious in HFrEF, the take home message is simply that if digoxin has been started and is tolerated, stopping it may cause clinical deterioration; it does not demonstrate that the drug is truly effective in the digoxin-naive HFrEF patient.”