Transcript Self-Evaluation Process 2009 Update in Hospital

27th Annual Family Medicine Review
Updates/Pearls in Office-Based and
Hospital-Based General Medicine
Stephen Sibbitt, MD, FACP
Chief Medical Officer, Scott & White Memorial Hospital
Asst. System Chief Medical Officer, Scott & White Healthcare
A few disclaimers…
ABIM style MCQs based upon
•
•
New emerging concepts/trends
•
•
•
I A level of evidence
IB or best available. The final vote is still out on many of
these.
Current (old) concepts
•
•
New literature
Re-emphasizing best practice
Special Thanks to Tresa McNeal, MD. Dept of Internal
Medicine, Scott & White Healthcare
Question 1






52 y.o male presents to the emergency room with 2-day history
of melena, epigastric discomfort, and lightheadedness. No
hematochezia, coffee-emesis, hematemesis.
Past history of 1-pack per day tobacco use (32 years),
osteoarthritis of right knee, and etoh abuse.
Medications include ibuprofen 600-800mg bid
On physical exam his BP = 110/70 supine, 90/50 sitting, HR is
115. Abdomen is soft, NABS, no rebound or masses, mild
epigastric tenderness. Rectal reveals melena, no masses.
Labs reveal normal platelets, PT and aPTT. Hgb is 9.6 mg/dl
Patient receives IV fluid resuscitation and undergoes EGD
revealing shallow gastric ulcer, biopsy negative for H. Pylori.
Following endoscopic treatment for bleeding peptic ulcers,
which of the following statements are true regarding highdose PPI therapy compared to non-high dose PPI therapy?
1.
2.
3.
4.
Decreased rate of rebleeding
Decrease in mortality
Decreased need for
surgical intervention
None of the above
25%
1
25%
25%
2
3
25%
4
10
Background

Endoscopy has reduced rates of re-bleeding, surgical
intervention, and mortality.

10-20% re-bleed after endoscopic intervention 4% mortality rate.

Many studies showing PPI > H2 Blockers in gastric acid
suppression and in controlling re-bleeding

Studies comparing high-dose PPIs to placebo have shown
reduced re-bleeding rates.

A meta-analysis demonstrated that non-high-dose PPIs
were also superior to placebo in terms of re-bleeding rates.
Literature search performed herein
Wang, C. H. et al. Arch Intern Med 2010;170:751-758.
Copyright restrictions may apply.
Study design

Combined 7 trials – 1157 patients

High-dose PPI = 80 mg bolus of omeprazole (Prilosec)
or pantoprazole (Protonix) followed by 8 mg/hour or
higher for 72 hours

Non-high-dose = IV PPI once daily or PO PPI twice
daily

-LOE = 1a
Systematic review (with homogeneity ) of randomized controlled trials
Effect of high-dose vs non-high-dose proton pump inhibitors (PPIs) on
rebleeding
Wang, C. H. et al. Arch Intern Med 2010;170:751-758.
Copyright restrictions may apply.
Effect of high-dose vs non-high-dose proton pump inhibitors (PPIs) on
surgical intervention
Wang, C. H. et al. Arch Intern Med 2010;170:751-758.
Copyright restrictions may apply.
Effect of high-dose vs non-high-dose proton pump inhibitors (PPIs) on
mortality
Wang, C. H. et al. Arch Intern Med 2010;170:751-758.
Copyright restrictions may apply.
Take home point

For patients with bleeding ulcers who are treated
endoscopically, high-dose proton pump inhibitors
compared to non-high dose PPI therapy



do not decrease the rate of re-bleeding,

Do not affect mortality,

Do not reduce the need for surgical intervention
Use non-high dose PPI (IV PPI once daily or PO PPI
twice daily)
LOE = 1a Systematic review (with homogeneity ) of randomized controlled trials
Question 2
• A 42-year-old male presents to the ED with syncope and
hypotension. The patient has a history of polysubstance abuse
including use of cocaine, etoh, marajuana, and has a dependence to
opiates. Current medications are lorazepam, disulfiram, and
methadone.
• Initially he is found to be becoming progressively more agitated
and having brief episodes of depressed conscious state, with
improvement between. He is ‘jittery’ and on vitals, he is found to
be afebrile with a fluctuating Glascow Coma Score, bradycardic,
and to have a systolic blood pressure of 80mmHg, respirations of
12, and so he is taken to a resuscitation cubicle.
• Initial ECG obtained and he experiences periodic arrythmias.
© 2010 ABIM
Which of the following medications is the most likely
cause of this patient's arrhythmia?
10
A.
B.
C.
D.
E.
Alcohol
Acetominophen
Benzodiazepines
Cannabis
Methadone
20%
A.
20%
20%
B.
C.
20%
D.
20%
E.
QT Prolongation

Caused by:








Hypomagnesemia
Hypokalemia
Hypocalcemia
Na channel blocking drugs (IA antiarrythmic)
Elevated intracranial pressure
acute coronary syndrome
Hypothermia
hereditary causes

Management is Magnesium and in more severe cases of recurrent Torsades an
implated defibrilator.

What caused QT prolongation in this patient


Methadone, effects potassium ion channels
causes significant increases in the QT interval (Martell et al, Am J Cardiol
2005;95:915-918)
Question 9
Question 2
Question 2 – Take Home Point

Chronic Methadone increases risk for malignant
cardiac arrhythmias.

Increase risk with higher doses (>40 mg/dl)

Pretreatment ECG to measure QTC interval

30-day follow up and annual ECG, after
initiation of chronic therapy
Question 3



62 y.o female recent move to your city; comes to see you to
established care. History of DMII, High Cholesterol, HTN
BP = 133/78 mmHg
Meds include




ASA 325 mg daily
Glyburide 10 mg po qday
Lisinopril 10mg po qd
Labs



HgbA1C = 7.6, Creatinine is 0.8
T-chol = 172mg/dl, LDL = 100mg/dl,
HDL= 38 mg/dl , TG= 174mg/dl,
You inform the patient that she requires treatment of her
lipids. You advise her that in DMII patients, in comparison to
statin treatment alone, the combination of a statin and a
fibrate, has been shown to:
10
1.
2.
3.
4.
Reduce the risk of
fatal cardiovascular
events
Reduce the risk of
non-fatal MI
Reduce the risk of
stroke
None of the above
25%
1
25%
25%
2
3
25%
4
Background

Increased atherosclerosis in DM patients

Statins are known to be efficacious in patients with
diabetes but CV events remain elevated even with
statins

VA-HIT ( 2001)trial showed decreased CV events with
fenofibrate use

FIELD (2008) trial showed benefit in reduction of total
cardiovascular events.

In previous trials, patients were not on statins.
Action to Control Cardiovascular Risk in Diabetes
5518
diabetic patients
2765
Fenofibrate + simvastatin
2753
Placebo + simvastatin
Mean follow-up was 4.7 years
Primary outcome
major fatal or nonfatal cardiovascular events
Secondary outcomes
Revasc or hosp for CHF
Major CAD event
Nonfatal MI
Stroke
Death
Would type 2 DM patients benefit from combination statin and fibrate
therapy?
Take home point

In diabetics, compared to simvistatin alone, the
combination of fenofibrate and simvastatin did not
reduce the rate of fatal or non-fatal cardiovascular
disease, non-fatal MI, or non-fatal stroke.

In patients with markedly elevated TG or very low
HDL, it is likely still worthwhile to initiate fenofibrate
therapy.
Question 4
 A 64-year-old man is referred to you following evaluation by his
orthopedist for total knee arthroplasty. He has a history of
progressive osteoarthritis that is described as severe for multiple
years, requiring use of a cane for ambulation. His orthopedist would
like him ‘cleared for surgery’. Surgery is scheduled in two weeks.
 Past Medical History pertinent for high cholesterol, hypertension,
and coronary artery disease. Seven months ago, he underwent drugeluting stent placement for worsening angina, and he has been
asymptomatic since the surgery.
 Current medications are aspirin, clopidogrel, lisinopril, metoprolol,
and simvastatin.
© 2010 ABIM
Following your evaluation which includes a normal ECG you advise
the following with respect to the placement of his DES and antiplatelet agents:
10
1.
2.
3.
4.
Proceed to surgery on
aspirin alone.
Proceed to surgery on
Plavix alone.
Stop ASA and Plavix
one week before
surgery and resume
immediately post-op.
Delay elective surgery
for 5 more months.
25%
1
25%
25%
2
3
25%
4
Question 4
Question 4
Management of patients with previous percutaneous coronary
intervention who require noncardiac surgery
Previous PCI
Balloon
Angioplasty
Time
since PCI
< 14 d
> 14 d
Delay for elective
or nonurgent
surgery
Bare-metal
stent
>30 – 45 d
Proceed to the
operation room
with aspirin
<30 – 45 d
Drug eluting
stent
<365 d
Delay for elective
or nonurgent
surgery
>365 d
Proceed to the
operation room
with aspirin
J Am Coll Cardiol 2007; 50:e159
Question 4...Take Home Point

The best available evidence:

elective surgery should be delayed at least 30 to 90
days following placement of a bare metal stent.

Elective surgery should be delayed at least one year
after drug-eluting stent placement.
Question 5. Is there any value in extending dual
antiplatelet therapy (aspirin plus clopidogrel) beyond
12 months after DES implantation?
10
1.
2.
3.
Yes, cardiovascular
outcomes are improved.
No, mortality is
increased.
Uncertain, further
randomized controlled
trials are required.
33%
1
33%
2
33%
3
Background

Drug-eluting stents significantly reduce restenosis.

May be associated with increased late stent thrombosis, death, or
MI.

Stopping dual antiplatelet therapy early is a risk factor for late
stent thrombosis in patients with drug-eluting stents.

Current guidelines recommend clopidogrel 75 mg daily for at
least 12 months.
The Question

Optimal duration of dual antiplatelet therapy
and the risk-benefit ratio for long-term
antiplatelet therapy are uncertain in the setting
of drug eluting stents.
The Study Design

Data merged from 2 similarly designed trials in Korea
(REAL-LATE & ZEST-LATE)

Enrolled people (2701) who had drug eluting stent
placed at least 12 months ago and who were still on
dual antiplatelet therapy

Randomly assigned to clopidogrel plus aspirin vs.
aspirin alone.

Primary endpoint of MI or death from cardiac causes
Factors to consider in interpreting
results

Not blinded

Inadequate sample size

Interval between stent placement and study
enrollment differed; unable to determine
optimal duration

New generation of stents may have different
performance.
Question 5…Take home point

ACC and AHA recommend dual antiplatelet rx in pts with DES.

Continuing dual antiplatelet therapy beyond 12 months is not
currently recommended for patients who have a drug-eluting
stent. Continued use did not improve outcomes and may worsen
them.

Larger clinical trials will be needed.

Dual Antiplately Therapy Trail (DAPT) ongoing


DES and BMS
12 vs 30 months of dual therapy
Question 6

67 y.o. male with chronic atrial fibrillation is seen in your office for routine
follow up. He reports his home heart rate monitor shows his HR runs
approximatetly 100 beats/min. He has no complaints of chest pain,
palpitations, lightheadedness, or dyspnea. He reports he feels fine and
continues to walk 3 miles per day without difficulty. He is concerned that his
HR should be lower.

He has been compliant with his medications consisting of Coumadin 5mg
daily, and metoprolol 25mg twice daily.

Vitals and physical exam normal with noted irregular rhythm with a rate of 98
beats/min. ECG reveals atrial fibrillation and is otherwise unchanged from
previous.
Question 6: You advise the patient that strict rate control (HR
<80 beats per minute) as compared to lenient rate control (HR
< 110 beats/min) is associated with which of the following?
10
1.
2.
3.
4.
Reduced risk of lifethreatening arrythmic
events.
Reduced risk of stroke.
No difference in risk of
cardiovascular death.
Reduced rate of
hospitalizations for heart
failure.
25%
1
25%
25%
2
3
25%
4
Background

Complications similar between rate and rhythm
control for atrial fibrillation.

Degree of rate control not previously studied.

AHA Guidelines recommend strict rate control
with target resting HR of 60-80 ranging up to
90-115 with exercise.
RACE II – Rate Control Efficacy in Permanent
Atrial Fibrillation
RACE II

Prospective, multicenter, randomized, openlabel

The Netherlands

Patients assigned to strict (resting HR <80)or
lenient ( resting HR <110) HR control using
Beta blocker or
 Ca channel blocker or
 digoxin

RACE-II

Followed every 2 weeks to titrate meds.

At the end of the dose adjustment phase, almost
all pts in the lenient group were at goal HR.
Only 2/3 of pts in the strict group.

Office visits
75 for lenient
 684 for strict

RACE II – Primary Outcome

Composite of death from the following causes:
CHF
 CVA
 Systemic embolism, major bleeding, arrhythmic
events, sustained VT, arrest, life threatening adverse
events, placement of PM or AICD

RACE II

At 3 years, the cumulative incidence of the primary outcome
between the 2 groups did not differ significantly
 12.9% lenient group
 14.9% strict group
Frequency of symptoms and hospitalizations were similar in the
2 groups.
Question 6…Take home point

AFFIRM trial, rate control is equivalent to rhythm
control in terms of survival.

In patients with permanent atrial fibrillation, lenient rate
control with a target resting HR<110 is as effective as
strict rate control in reducing adverse outcomes without
increasing symptoms or number of hospitalizations.

This can be achieved with less meds and less clinic
visits in general.
Question 7
 A 32-year-old male presents to the emergency department
with 6 hour complaint of substernal chest pain. Patient
admits to habit of crack-cocaine use. Denies any other
illicit drug use. No other past medical history and denies
family history of coronary disease.
 Physical exam reveals blood pressure of 148/88 mmhg,
heart rate of 88 beats/min , and respiratory rate of 14
breaths/min.
 Cardiac enzymes (creatine kinase and troponin) are normal.
ECG is normal without evidence of ischemia.
© 2010 ABIM
Which of the following is the best treatment
option for this patient?
A.
B.
C.
Treat with aspirin and a
benzodiazepine and observe until
chest pain resolves
Treat with aspirin and a betaadrenergic blocking agent, order
complete cardiac enzyme studies,
then discharge after pain
resolves.
Treat with aspirin alone and
order complete cardiac enzyme
studies, then order a stress test
before discharge
33%
A.
33%
B.
10
33%
C.
Cocaine and the heart

Increase myocardial oxygen demand
Increase HR
 Increase BP (peripheral vasoconstriction)
 Increase contractility


Acute Thrombosis
Increase platelet activation
 Increase platelet aggregation


Early atherosclerosis

Seen on autopsy of young cocaine users
β-Blockers for Chest Pain Associated With Recent Cocaine Use
Carlos Rangel; Richard G. Shu, MD; Lawrence D. Lazar, MD; Eric Vittinghoff, PhD;
Priscilla Y. Hsue, MD, MAS; Gregory M. Marcus, MD, MAS
Arch Intern Med. 2010;170(10):874-879.
Background: Recommendations against this use of β-blockers are based on animal studies,
small human experiments, and anecdote.
Methods Retrospective cohort study of consecutive patients admitted to the San Francisco
General Hospital, San Francisco, California, with chest pain and urine toxicologic test results
positive for cocaine. Mortality data were collected from the National Death Index.
Results Of 331 patients with chest pain in the setting of recent cocaine use, 151 (46%) received
a β-blocker in the emergency department. There were no meaningful differences in
electrocardiographic changes, troponin levels, ventricular tachycardia or ventricular fibrillation, or
death between those who did and did not receive a β-blocker.
Conclusion β-Blockers do not appear to be associated with adverse events in patients with
chest pain with recent cocaine use
Treatment algorithm for patients with cocaine-associated chest pain
Schwartz, B. G. et al. Circulation 2010;122:2558-2569
Copyright ©2010 American Heart Association
Question 7…Take Home Point

Cocaine-induced chest pain without ECG changes or elevated biomarkers can
be managed conservatively with aspirin, nitrates, and benzodiazepines.

Beta-adrenergic blocking agents continue to be contraindicated because they
can cause unopposed alpha stimulation that can worsen ischemia. However
recent uncontrolled study cast some doubt on this.

Stress tests have a high false-positive rate in the setting of recent cocaine use
and should be delayed or avoided.
Question 8
A correlation exists between the use of proton pump inhibitors
and which of the following?
Clostridium difficile
colitis
Hospital-acquired
pneumonia
Osteoporosisrelated fracture
A)
No
No
No
B)
Yes
Yes
No
C)
No
Yes
Yes
D) Yes
Yes
Yes
© 2010 ABIM
A correlation exists between the use of proton
pump inhibitors and which of the following?
10
25%
A.
B.
C.
D.
25%
25%
B.
C.
25%
A
B
C
D
A.
D.
Question 8
Question 17
Question 17
Question 8…Take Home Point

Several studies now show a correlation between PPI
use and each of the conditions mentioned in the
table.

PPIs overuse is widely reported, and clinicians
should be aware of potential complications.
Question 9

A 58-year-old woman was diagnosed with Clostridium
difficile colitis following a course of antibiotics for
pyelonephritis. Symptoms resolved entirely after
treatment with a 14-day course of metronidazole.

Ten days after completing the antibiotic course, the
patient reports a two-day history of abdominal pain and
diarrhea. She has not had fever or blood in her stools,
but reports seven bowel movements during the past 24
hours.
Question 9

Temperature is 37.1 C (98.7 F), pulse rate is 85 per
minute, respirations are 14 per minute, and blood
pressure is 105/62 mm Hg. The abdomen is soft, and
examination reveals mild diffuse tenderness; bowel
sounds are decreased. No peritoneal signs are detected.
Leukocyte count is 13,600/μL, serum albumin is 3.2
g/dL, and stool assay for Clostridium difficile toxin is
positive.
Which of the following oral agents should
you prescribe next?
10
25%
A.
B.
C.
D.
25%
25%
B.
C.
25%
Cholestyramine
Metronidazole
Rifampin
Vancomycin
A.
D.
Question 9
Question 9…Take Home Point

Relapse rate of Clostridium difficile colitis is 10-25%

Relapse typically occurs one to two weeks after antibiotics are
discontinued, but can occur months later.

Initial relapse with non-severe disease should be treated with
a second course of metronidazole; has been shown to be
noninferior to vancomycin.

Patients with a second relapse or with severe disease should
be treated with oral vancomycin.

Severe disease defined as age > 60, T > 38.3 C (100.9 F), WBC >
20,000/microliter, albumin < 2.5 g/dL, and more than ten bowel movements
daily)
Question 10. Supplementation with which of the
following vitamins has been shown to lower the risk
of prostate cancer?
25%
Vitamin E
A.
B.
C.
D.
25%
25%
B.
C.
25%
Vitamin C Selenium
Yes
Yes
No
No
No
Yes
No
No
:10
Yes
No
Yes
No
A.
D.
Question 16
Question 10…Take Home Point

Previous studies (observational) suggested certain
vitamin supplements may be effective for primary
prevention of prostate cancer,

Recent randomized, controlled trials failed to show any
benefit of vitamin E, vitamin C, or selenium in reducing
the risk of prostate cancer or all-cause mortality.