Sep 6, 2019

Conference call

The story

Only in residency do tales of the heart have you thinking codes rather than romance. But if night shift kept you from a trip to Paris this weekend, here are our favorites from the European Society of Cardiology annual meeting.

Thick and thin

Less is more never applied to transport techs, but in general de-escalation of blood thinners is in vogue. AFIRE compared rivaroxaban monotherapy to rivaroxaban + an antiplatelet agent in 2,200 a-fib patients with stable coronary artery disease (> 1 year since PCI, CABG, or cath diagnosis of CAD). Monotherapy was noninferior to combination therapy for a composite endpoint of major CV events or systemic embolism over median follow-up of 2 years (event rate 4.1 vs. 5.8%), and it was superior for the primary safety endpoint of major bleeding (1.6% vs. 2.8%).

Deep cuts

Observational data continues to show promise in the absence of randomized trials comparing bariatric surgery to medical management for patients with type 2 diabetes (T2D). A retrospective analysis of 2,300 obese T2D patients who underwent bariatric surgery found improvements in 6 prespecified outcomes compared to matched controls, including all-cause mortality (10% vs 18% in controls over median follow up of 8 years), major CV events, a-fib, and nephropathy. The current study included higher-risk patients (greater morbidity and higher insulin usage) than previous studies, though all have shown large benefits favoring surgery.  

Head on

ISAR-REACT 5 compared early (pre-cath) ticagrelor and late (after diagnostic cath) prasugrel in 4,000 patients with acute coronary syndrome. Both meds were continued for 1 year. The investigators hypothesized that outcomes would favor ticagrelor, but the prasugrel group had a lower incidence of death, myocardial infarction, or stroke (6.9% vs. 9.3%) at 1-year follow-up with no between group differences in bleeding rates. The study is the first to show a head-to-head difference between highly potent antiplatelet agents. 

Say it on rounds

When you had evening plans, until your pager went off

Structure isn't really our thing, but an 800-patient RCT of women with late preterm pre-eclampsia (34 - 37 weeks gestation) found a lower rate of maternal morbidity and systolic hypertension following planned (early) delivery compared to expectant management (65% vs. 75%). Despite more neonatal unit admissions for prematurity in the planned group, there was no difference in infant morbidity, meaning both mom and baby did well.

When the whole room yawns at morning report

There’s power in collective participation. An analysis of 3 colon cancer screening strategies across 30,000 patients found that participation among invited patients was markedly higher among those assigned to fecal immunochemical testing (FIT, an at home stool based test) than flexible sigmoidoscopy or colonoscopy (77% vs 31% vs 24%). While colonoscopy was highly sensitive for advanced neoplasia (AN) among screened patients, FIT produced the highest diagnostic yield in the intention to screen analysis.
Clin Gastro Hepatol

Brush up

Adrenal crisis

Around 6 - 8% of patients with adrenal insufficiency will have incident adrenal crisis each year. Look for acute changes in health accompanied by hypotension (SBP < 100 mm Hg or > 20 mm Hg below usual) that resolves within 1 to 2 hours of IV hydrocortisone. Common symptoms include GI upset, delirium, obtundation, and fever, while hyponatremia, hyperkalemia, and hypoglycemia are common on labs. Consider other causes if symptoms do not improve with steroids.

What's the evidence

For risk factors for adrenal crisis? A 2014 retrospective study of 820 patients admitted with adrenal crisis in Australia found that admission rates increased with each decade over age 60. A majority of patients were women (62.5%), and 39% of patients presented with concomitant infection. Gastroenteritis, which can prompt adrenal crisis by reducing oral steroid absorption, was present as a secondary diagnosis in 15% of admissions.

What your burning man friends are talking about

We understand that the comedown from the burn can be rough, but here’s some soothing news: Hopkins made a splash by opening a new $17 million center to further study the benefits of psychedelic medicine

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