T HE T OP 5 P APERS OF 2017 Amol Verma MD MSc FRCPC Kieran Quinn MD MSc FRCPC
• No Disclosures
T OP 5 P APERS • PFO closure in stroke • PE in syncope • Re-evaluating asthma diagnosis • BNP-guided treatment in heart failure • Opioid prescribing in ED
I S T HAT A PFO S IGHTING ?
C ASE 1 • 47F with left MCA stroke. • No atrial fibrillation, no signs of hypercoagulability, no large vessel atherosclerotic disease. • PFO found on TTE. “Should I refer to cardiology for PFO?”
T HE B OTTOM L INE • This multinational randomized trial of PFO closure in younger patients with cryptogenic stroke demonstrated a reduction in recurrent clinical stroke • NNT = 28 at 24 months
• Design – Multinational RCT, open-label • Participants: – 664 patients 18-59 yo (45 yrs) • 25% HTN, 4% DM – Cryptogenic stroke – PFO on TEE, with signs of R-L shunt • Comparison: – PFO Closure + Antiplatelet vs. Antiplatelet alone
• Outcomes (followed 2-5 yrs): – clinical stroke: 1.4% vs. 5.4% – silent stroke: 4.4% vs. 4.5%
• Safety Outcomes – Procedure-related: 2.5% – Device-related: 1.4% • Dislocation 0.7% • Thrombosis 0.5% • Aortic Dissection 0.2% – Atrial Fibrillation 6.6% vs. 0.4%
D ISCUSSION • Other studies: – CLOSE trial, RESPECT long-term outcomes • Key differences between older trials – Careful patient selection • Limitations – Differential rates of follow-up – Lack of prolonged cardiac monitoring – Unblinded, ? referral bias for clinical stroke
T AKE -H OME M ESSAGE PFO closure is compelling … …in patients who are younger than 60, have cryptogenic non-lacunar stroke, and who have a PFO with (moderate-large) shunt.
C ASE 1 • 47F with left MCA stroke. • No atrial fibrillation, no signs of hypercoagulability, no large vessel atherosclerotic disease. • PFO found on TTE. “Should I refer to cardiology for PFO?”
T O PE OR N OT TO PE
C ASE 2 • 76F presents to ED with first episode of syncope. • History not suggestive of vasovagal, situational, or orthostatic cause • Normal ECG, normal cardiac examination. • No clear etiology “Should I work-up for Pulmonary Emboli?”
T HE B OTTOM L INE • This multicenter cross-sectional study of 560 Italian patients admitted for their first episode of syncope identified pulmonary embolism in 17% of individuals.
• Design: – Prospective multicenter cross-sectional study – Blinded adjudication of outcomes • Participants: – 560 patients, 72-85 yo (76 yrs) – First episode syncope (not due to seizure, stroke or head trauma) • Exposure: – Stratified into PE “likely” or “unlikely” (Well’s score and D-dimer results) – “Likely” (Well’s >4, D-dimer>250-500 ug/mL) • CTPA or V/Q scan
• Outcomes: – 97/560 (17%) had PE • 45/97 (46%) individuals with PE also had alternative explanation
D IAGNOSTIC Y IELD (GEMINI V . PESIT)
B ASELINE C HARACTERISTICS • 24/97 (25%) had no signs or symptoms of PE
T AKE -H OME M ESSAGE Syncope is a challenging diagnosis … …patients should receive systematic clinical assessment (Wells Score +/- investigations) for pulmonary embolism.
C ASE 2 • 76F presents to ED with first episode of syncope. • Normal ECG, normal cardiac examination. • History not suggestive of vasovagal, situational, or orthostatic cause • No clear etiology “Should I work-up for Pulmonary Emboli?”
A IRWAY TODAY , GONE TOMORROW ?
C ASE 3 • 53M diagnosed with asthma several years ago. • Has never smoked. • May have had PFTs, but not quite sure. • Takes daily budesonide/formoterol. • Occasional dyspnea on exertion. “Should I order PFTs? Should I try to taper asthma medications?”
T HE B OTTOM L INE • This multicentre prospective cohort study showed that 1/3 of adults with physician- diagnosed asthma did not have the diagnosis on subsequent testing and could be safely tapered off of medications.
• Participants: – Random digit dialing in 10 largest cities in Canada – Adults with physician-diagnosed asthma in past 5 years – Excluded: > 10 py smoking • Intervention/Measurements: – Diagnostic algorithm of spirometry with bronchodilator and methacholine challenge – Follow-up for 12 months – Contacted MD offices re: initial diagnosis
R ESULTS • 701 adults entered study, and 613 completed study – 87% recently using asthma medications – 45% daily use of asthma medications • Asthma ruled out in 33% – 97% did not re-start meds after 12 months
• Rate of asthma testing was 51% – Tested à more likely asthma confirmed • Results at diagnosis not always confirmed on repeat testing: – At least 16% negative to positive – At least 12% positive to negative
D ISCUSSION • Reason for change in asthma diagnosis: – Misdiagnosis – Natural history of disease – Change in environmental exposures • Limitations – Selection bias – Mild-moderate asthma (less severe)
T AKE -H OME M ESSAGE • Spirometry must be part of asthma diagnosis • Worth revisiting the diagnosis – With close follow-up, medications can be safely stopped for up to 1/3 patients
C ASE 3 • 53M diagnosed with asthma several years ago. • Has never smoked. • May have had PFTs, but not quite sure. • Takes daily budesonide/formoterol. • Occasional dyspnea on exertion. “Should I order PFTs? Should I try to taper asthma medications?”
D ON ’ T S TOP BNP IN ’?
C ASE 4 • 62M with HF for just over 1 year • LVEF 25%, NYHA 2-3 with CAD and DM on a b -B and an ACEi • Recent hospitalization, with NT-proBNP 2653 pg/mL “Should I repeat his BNP in clinic? Should this guide therapy?”
T HE B OTTOM L INE • In patients with chronic HFrEF, there was no difference in time to first hospitalization or cardiovascular mortality using a BNP- guided strategy, raising doubts about its utility in management.
• Design: – Unblinded multicenter RCT • Participants: – 894 patients 51-72 yo (63 yrs) • ~50% CAD, ~90% on BB, ~70% ACEi, ~50% MRA – NT-proBNP > 2000 pg/mL (BNP > 400 pg/mL) – Decompensated HF within 1 year • Comparison: – NT-proBNP target <1000 pg/mL v. Usual Care without BNP • Focus on neurohormonal therapies, not diuresis
• Outcomes at 1 year: – Hospitalization or CV Death: 33.8% v. 36.0% – All-cause mortality: 15% v. 17%
• Limitations: – Only 45% achieved ‘target’ BNP – 50% reduction in BNP in all individuals
T AKE -H OME M ESSAGE Management of chronic heart failure … …should not include the use of BNP to guide titration of therapies for those with HFrEF… but adhering to guidelines works!
C ASE 4 • 62M with HF for just over 1 year • LVEF 25%, NYHA 2-3 with CAD and DM on a b -B and an ACEi • Recent hospitalization, with NT-proBNP 2653 pg/mL “Should I repeat his BNP in clinic? Should this guide therapy?”
“T HE P ATH TO D ISCHARGE IS P AVED WITH P ERCOCET ”
C ASE 5 • 67F with back pain who visits the ED for sudden and severe onset of pain. • Found to have osteoporotic vertebral compression fracture. • Plan to discharge home from ED. “I’ll give her a short course of opioids, how much harm could it do?”
T HE B OTTOM L INE • This large observational study found that long-term opioid use was more common among ED patients who received a prescription from high-intensity prescribers than low-intensity prescribers. • 48 opioid prescriptions à 1 long-term user
Participants: • 20% random sample of US Medicare beneficiaries 2008-2011 (n=375,000) • ED visit and not admitted to hospital • No opioid Rx filled in 6 months prior Exposure: • Doctors categorized as ‘high intensity’ or ‘low intensity’ prescribers Outcome: • Long-term opioid use: ≥ 180 d opioids in 12 months
1.51% 24.1% 7.3% 1.16%
R ESULTS • NNH: – 48 opioid prescriptions à 1 long-term user • Small increase in opioid-related hospitalizations • No signs of ‘undertreatment’ in low- intensity group
T AKE -H OME M ESSAGES • Opioid prescribing varies widely (3-fold) among ED physicians • Meaningful, but modest, differences in long-term opioid use (0.35%, NNH 48) • Episodic care can cause harm
C ASE 5 • 67F with back pain who visits the ED for sudden and severe onset of pain. • Found to have osteoporotic vertebral compression fracture. • Plan to discharge home from ED. “I’ll give her a short course of opioids, how much harm could it do?”
T HE T OP 5 P APERS OF 2017 Amol Verma MD MSc FRCPC Kieran Quinn MD MSc FRCPC
SUPPLEMENTARY SLIDES
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O PIOIDS
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