6/23/2015 2014 (and early 2015) How to make this talk…. The Year in Review Areas Searched No conflicts of interest • Medline • ACP Journal Club • Residency Journal Clubs • Faculty Suggestion • Practical, Applicable, Interesting • Whatever is not being covered elsewhere…. TIA and Stroke Topics! A 75 year old woman arrives a week after being sent home from the ER after experiencing 2 hours of mild dysarthria. She was 1- Diagnostics diagnosed by neurology with a TIA. Her CTA showed no carotid or vertebral vascular disease, her tele no afib and she had a -Stroke and TIA normal echo. She is on atorvastatin for hyperlipidemia and 2- Imaging chlorthalidone for well controlled hypertension. She is on clopidogrel for a coronary stent. You recommend which of the 2a- Stones following: 36% 34% 2b- Lung screening A. Add aspirin to clopidogrel 26% B. Change atorvastatin to rosuvastatin 3- Therapeutics C. Change chlorthalidone to atenolol 3a- Soft tissues 4% D. Ambulatory cardiac monitoring for one month 0% 3b- DAPT duration E. Order carotid ultrasound d e l . . . . n r . . . . u g . o n o r t o o d o m s e a p i t n n o c t r o l l t i d a u c a i d i l d o s t a r t a h a t i t c o n v r i r o y r r o r a p i t h l o c a t s c a r a e e e l d d g g u d n n b O r a m A a h h C C A 1
6/23/2015 Match Trial Burden of Disease - Stroke Secondary Prevention: Plavix + Aspirin or - 12 million annual strokes Plavix + Placebo - 3 rd leading cause of death in • N=7599 followed for 18 months Western World • Outcomes: CVA, MI, hospitalization or death - 200,000 deaths in U.S. annually – Dual Rx. 596/3793 (15.7%) – Clopidogrel 636/3802 (16.7%)- no asa alone arm…. - 15-20% mortality per event – RRR 6.4% (-4.6-16.3) – Significant increase in bleeding on dual therapy - 18% unable to return to work - 4% total custodial care • Conclusions: Dual Rx no better than clopidogrel alone Aprox $60 Billion U.S. annually – VA Neuro- change antiplatelet agent » Lancet Vol. 364 July, 2004 AHA, 2012 Heart and Stroke Statistical Update Hypertension is the biggest stroke Cryptogenic stroke risk factor… BUT • Stroke evaluation includes** – 12 lead EKG with 24 hour holter (or tele) – Brain and neurovascular imaging – Echocardiography (+ bubble study) – AHA Guidelines. Stroke 2013;44 • Cerebrovascular events without a cause after standard evaluation – 20-40% strokes – 50% of TIAs American Heart Association, 2002 Heart and Stroke Statistical Update , 2
6/23/2015 Rate vs Rhythm Control on Stroke Atrial fibrillation follow-up investigation of rhythm management- AFFIRM Randomized 4060 patients to cardioversion vs rate control All received coumadin - Common disorder, increases with age - Stroke risk increases: - Rate control=rhythm control - 17X for valvular afib - -paroxysmal afib=chronic afib - 5 times for nonvalvular - How to RX? Circulation 201: 103:162-182 Stroke Prevention in A. Fib-Rx Warfarin Versus Aspirin 5 Trials with 2837 participants and 205 strokes over 2 years Meta-analysis Data – 9874 participants, 16 trials 1. Warfarin vs. Placebo � 62-68% RRR INR 2-3 - Absolute risk bleeding 0.3%/year - Reduction of all cause mortality 26% (ARR 1.6%/Year) 2. Aspirin vs. Placebo � 21-22% RRR ANY Dose - Absolute risk bleeding 0.2%/Year - No overall reduction of mortality Relative risk reduction 36% favoring warfarin -NNT 167 primary prevention - NNT 14 secondary prevention (includes TIA) -AR major bleeding 0.2%/ year increase with warfarin Annals of Internal Medicine Vol. 131, No. 7 Annals of Int. Medicine Vol. 131, No. 7 October 5, 1999 3
6/23/2015 Cardiac Monitoring Cryptogenic Stroke CHADS 2 Prediction Rule - don ’ t always agree AFI, SPAF - 2 large prediction rule trials • 2 large RCTs of 30 day monitor vs. 24 hours – Outcome: Incident atrial fibrillation (> 30 sec) - Framingham hard to use • Embrace Trial C – CHF in last 100 days – 572 patients, age 73, 89% white H – Hypertension – 30 day event triggered recorder vs. standard – New afib >30 seconds A – Age >75 Years Score • Crystal-AF Trial 0=1% D – Diabetes 1=2.5%/year 4=8% – 441 patients, age 62, 87% white 2=4% 5=12% – Implantable loop recorder S 2 – x2 previous Stroke or TIA 3=6% 6=18% • NEJM 370;26 June 26, 2014 Gage et al. JAMA June 13, 2001 EMBRACE TRIAL 42/284 35 33 21 NNS=9/30 days Atrial fibrillation 6 of 277 (3.2%) 6 of 277 (3.2%) 6 of 277 (3.2%) 6 of 277 (3.2%) controls Gladstone DJ et al. N Engl J Med 2014;370:2467-2477. Gladstone DJ et al. N Engl J Med 2014;370:2467-2477. 4
6/23/2015 Case Outcome Cryptogenic Stroke Conclusions • Limitations: • 75 year old woman post – Primary Outcome- > 30secs afib TIA- 30 day – Not designed to show reduced stroke monitor patch- discovered to • Implications: have afib and – Cryptogenic stroke patients should receive 30 started on days of cardiac monitoring for atrial fibrillation coumadin – Anticoagulation decisions based on results Case #2 Nephrolithiasis 40 year AA old man with difficult to control ulcerative colitis • Common: 2.5 million visits/year and chronic diarrhea presents with 12 hours of worsening • $2 billion per year in US flank pain that radiates to his right testicle. He has microscopic hematuria on dipstick urine. You suspect • 16% men and 8% women will have at nephrolithiasis. Your initial evaluation should include: least one symptomatic stone by the age of 70 years 47% A. Home to push fluids • 80 percent calcium oxalate B. Ultrasound for stone evaluation • Recurrence: 28% C. Non-contrast CT scan 15 percent at one year, 40 percent 17% at five years, and 50 percent at 10 years D. 24 hour urine collection 7% E. A and D 2% • Goal: Avoid high risk complications Home to push fluids Non-contrast CT scan 24 hour urine collection A and D Ultrasound for stone eva... – Sepsis, Obstruction, Renal Failure, Hospitalization 5
6/23/2015 CT Scan Cancer Risk Stone Evaluation • 2 Evaluations: Conservative vs. Aggressive – Conservative- • First time without other risks • UA, Culture, stone analysis • No immediate imaging – Aggressive- • Diabetes, chronic diarrhea, AA, gout, elderly, CKDz • UA, Culture, stone analysis • Imaging- Helical CT scan NNH one cancer in 40 year old man = 1002 –Radiation exposure.. Smith-Bindman Arch Intern Med. 2009;169(22):2078-2086 Imaging for Nephrolithiasis Results: • RCT 2759 patients in ER • High Risk Diagnosis- 0.4% overall p=0.3 (40yo, 40% white, 24% AA, 24% Hispanic) • Radiation Exposure- 10mSv vs. 17mSv p<0.001 • POC Ultrasound (908) • Radiology US (893) • Secondary Outcomes: • Non-Con Helical CT (958) – Serious adverse events: 11% p=0.5 – Return ER visits: 10% one week p=0.43 • 1 outcome- Immediately life threatening – Hospital admit: 3% one week p=0.21 • 2 outcome- Serious adverse events – Pain score: 2.0 one week p-0.80 – Smith-Bindman N Engl J Med 2014; 371:1100-1110 – Smith-Bindman N Engl J Med 2014; 371:1100-1110 6
6/23/2015 Case #3 Imaging in Nephrolithiasis A 60 year old man, never-smoker, arrives requesting screening for lung cancer. He had a 1mm LLL nodule • Ultrasound (either radiology or POC) good without spiculations on CXR. He is an economist and asks initial screen societal costs. You decide: • Radiation lower A. Lung cancer screening costs more than dialysis 61% B. Lung cancer specific mortality is not improved with screening POC Rad US Non-con C. It is cheaper to screen older patients for lung cancer • Sn= 85 84 86 15% 12% D. Costs depend dramatically according to lung 10% 2% • Sp= 50 53 53 cancer risk profile E. I only screen in non-smokers if they are litigating Lung cancer screening co... Lung cancer specific mort... Costs depend dramaticall... I only screen in non-smo... It is cheaper to screen ol... lawyers • Smith-Bindman N Engl J Med 2014; 371:1100- 1110 CT Scan Cancer Risk Lung Cancer Screening • NSLT – National Lung Screening Trial – 53K patients CXR vs. helical CT x3 – 20% reduction in lung cancer mortality – 18 vs. 21/1000 pts died over 6.5 years – NNS 333 to save one life from lung cancer • Aberle et al. NEJM 2011;307 • USPT grade B (benefit moderate-significant) NNH one cancer in 60 year old man = 2080 • Private insurance must cover.. Smith-Bindman Arch Intern Med. 2009;169(22):2078-2086 7
6/23/2015 Cost by Subgroups Women Age 60-69 Current Smokers Highest Quintiles of risk Black et al. NEJM 371:19 Nov. 6 2014, Risk Calculator- NEJM 2013; 368:728-736 http://reference.medscape.com/calculator/solitary-pulmonary-nodule-risk Lung cancer screening Follow USPTF recs: “now recommends annual screening for lung cancer with low- dose CT in people 55 through 80 years old with a 30 or more pack year history of smoking who are currently smoking or have quit within the past 15 years.” Stay tuned for sharpening tool for screening as more data comes through! http://reference.medscape.com/calculator/solitary-pulmonary-nodule-risk Risk Calculator- N Engl J Med 2013; 368:728-736 8
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