Updates in General Internal Medicine 2019 No conflicts of interest - PowerPoint PPT Presentation

Updates in General Internal Medicine 2019 No conflicts of interest jeff.kohlwes@ucsf.edu

Topics! CV Updates in Primary Care - Anticoagulation in afib - Risk factor reduction - Steppin’ out for health - WCH vs. WCE Important Surgical Outcomes for Primary Care - AAA repair Public Health in Primary Care - It’s legal - Not the elixir of health Epidemiology of Fear

Case #1- A 70-year-old asymptomatic diabetic man with CAD post PCI with DES stent in the LAD 14 months ago with rate controlled atrial fibrillation on apixaban, amlodipine, atorvastatin, metoprolol and aspirin presents for routine primary care. BP- 118/78, HR- 80, RR- 12, 99% saturation. You recommend: A- Continue all medications B- Add clopidogrel to ensure DAPT C- Increase amlodipine to lower SBP D- Stop aspirin for single anticoagulation agent E- Increase metoprolol for rate control

Case #1- A 70-year-old asymptomatic diabetic man with CAD post PCI with DES stent in the LAD 14 months ago with rate controlled atrial fibrillation on apixaban, amlodipine, atorvastatin, metoprolol and aspirin presents for routine primary care. BP- 118/78, HR- 80, RR- 12, 99% saturation. You recommend: A- Continue all medications B- Add clopidogrel to ensure DAPT C- Increase amlodipine to lower SBP D- Stop aspirin for single anticoagulation agent E- Increase metoprolol for rate control

Afib+Anticoag in Stable CAD - 18.2 million adults age 20 and older have CAD - 1 in 4 deaths in the U.S. - 5-7% of PCI pts with atrial fibrillation - Common disorder, increases with age (mirrors CAD) Circulation 2011: 103:162-182 - Warfarin vs. Placebo- 66% RRR INR 2-3 Annals I. M. Vol. 131, No. 7 October 5, 1999 What is the right anticoagulation plan post PCI?!

Anticoagulation- Afib post PCI - First 12 months Canadian Guidelines (European similar) Restenosis risk first month- slowly decreases over 12 months -Canadian Journal of Cardiology, Vol. 34, March 2018, Pages 214-233

Anticoagulation- Afib post PCI -After 12 months • A trial F ibrillation and I schemic events with R ivaroxaban in pati E nts with stable CAD (AFIRE) Trial • Open label RCT, Japan Ministry funded • 74 yrs, 79% men, CHADS2=2, HAS-BLED=2 2236 patients >12 mos post PCI with afib 1108 Rivaroxaban + 1107 rivaroxaban antiplatelet (70% asa) Stroke, Systemic Emboli, ACS/MI, Revascularization, death Yasuda et al- NEJM 2019 Sep 19;381(12):1103-1113

AFIER (afire) Results ITT Analysis- stopped early for mortality benefit monotherapy rivaroxaban • 2 years average follow up • HR 0.72 • 4.1 % mono vs. 5.7% aPLT  NNT= 62.5 / 2 years  NNT mortality = 67 / 2 years Major Bleeding- 2.8% vs. 1.6%  NNH = 83 / 2 years with aPLT Yasuda et al. NEJM 2019 Sep 19;381(12)

Case continued You stop the patient’s asa and continue monotherapy rivaroxaban. He returns 2 months later for routine follow up. His EP physician suggests a catheter-based ablation procedure. He wants to know if he can change his lifestyle to maintain sinus rhythm. You tell him: A- Anticoagulation can be stopped immediately after procedure B- Paroxysmal afib has the same success rate as chronic afib post ablation C- Alcohol abstinence reduces atrial fibrillation in drinkers D- Two of the above

Case continued You stop the patient’s asa and continue monotherapy rivaroxaban. He returns 2 months later for routine follow up. His EP physician suggests a catheter-based ablation procedure. He wants to know if he can change his lifestyle to maintain sinus rhythm. You tell him: A- Anticoagulation can be stopped immediately after procedure (Wait at least 2-3 months only with cards OK!) B- Paroxysmal afib (70-80%) has the same success rate as chronic afib (60-70%) post ablation C- Alcohol abstinence reduces atrial fibrillation in drinkers D- Two of the above

Cool study on ETOH-Afib • RCT- open label 63 years, 85% men, 500 excluded 140 patients 70 control 70 abstinence Freedom from A. Fib >30 sec Total Afib Burden -Voskovoinik et al. NEJM Jan. 2, 2020

Baseline drinking behaviors

Abstinence helps.. 6 Months Follow Up: Abstinence group  2 drinks/week (88% decrease), control  13/week (20%) - - Afib recurrence: 37 (53%) abstinence group vs. 51 (73%) control group - NNT to not Drink- 5 - Clinical relevance? Likely! -Voskovoinik et al. NEJM Jan. 2, 2020

Case continued 3 months later the 70-year-old asymptomatic patient returns feeling great. He wants to walk with his partner but is intimidated by walking > 10K steps. How many steps does he need to take to start seeing mortality benefit over 4-5 years? Which of the following is true? A- Sorry its 10K or bust B- Mortality doesn’t reduce unless you make it 7500 steps C- Biggest incremental mortality benefit is seen over 7500 steps D- Mortality benefits begins at 3000 steps daily E- B and C

Case continued 3 months later the 70-year-old asymptomatic patient returns feeling great. He wants to walk with his partner but is intimidated by walking > 10K steps. How many steps does he need to take to start seeing mortality benefit over 4-5 years? Which of the following is true? A- Sorry its 10K or bust B- Mortality doesn’t reduce unless you make it 7500 steps C- Biggest incremental mortality benefit is seen over 7500 steps D- Mortality benefits begins at 3000 steps daily E- B and C

Step Volume and Mortality • 17K pts WHS Difference at • 7 days steps/day 3000 steps HR-0.75 Max effect at >7500 steps HR-0.45 accelerometer Survival Curve Levels - 7500 steps Lee- JAMA IM 2019;179(8)

Afib/CAD updates • Rivaroxaban monotherapy after one year – Coordinate with cardiologists • Alcohol abstinence with afib • WALK!! – 3,000 to 7,500 steps for max benefit

Case continued The patient’s 65-year-old partner is your next patient and he has a BP=144/90. His BP has never been elevated before and on repeat he is 128/80. He says it is never high at home (he checks at pharmacy). What should you do? A- Nothing, he is normotensive on repeat B- Start low dose amlodipine C- Ambulatory BP monitoring D- Have him rest and repeat a third time

Case continued The patient’s 65-year-old partner is your next patient and he has a BP=144/90. His BP has never been elevated before and on repeat he is 128/80. He says it is never high at home (he checks at pharmacy). What should you do? A- Nothing, he is normotensive on repeat B- Start low dose amlodipine C- Ambulatory BP monitoring D- Have him rest and repeat a third time

Hypertension (HTN) • HTN dxed 80 million people in U.S. – Only 54% controlled – Tightly a/w CV outcomes • Measurement error common – Cuff size, body position, talking, haste – 2 nd measure, (−)8mmHg – Leads to less treatment • Einstader JAMA Intern Med. 2018;178(6) • Do we care about missing white coat HTN? Risk of stroke with HTN Rx

Relationship between Clinic/Ambulatory BP Measures Cox CV covariates Cox CV and BP (rxed) White Coat HTN is not benign- HR 1.96 Cohort study from Spain Banegas NEJM 2018; 378:1509-1520

White Coat HTN • Meta-analysis – 27 studies, 26K patients – 56 years old, 8 years follow-up • Predictors: – untreated WCH or treated WC Effect (WCE) • Outcomes: – CV Events, all cause mortality, CV mortality – Cohen et al. Ann Intern Med. 2019;170:853-862

White Coat Hypertension Cohen et al. Ann Intern Med. 2019;170:853-862 • CV Outcomes Fewer WCH More WCH 36% increase CV outcomes No difference for Treated White Coat HTN • Mortality Outcomes 33% increased Mortality!!

Bottom Line HTN Screening • Beware White coat HTN • Ambulatory (or Home?) BP measures useful • Good coaching to measure correctly! • Treat to guidelines Stroke reduction !

Case #2- When talking about Abdominal Aortic Aneurysms which of the following statements is true? A- Risk of rupture increases exponentially when AAA measures >4.5cm B- Smoking is the biggest risk factor for AAA C- Family history of AAA is not a risk factor D- Screening for AAA has no impact on disease specific mortality E- All of the above are false

Case #2- When talking about Abdominal Aortic Aneurysms which of the following statements is true? A- Risk of rupture increases exponentially when AAA measures >4.5cm B- Smoking is the biggest risk factor for AAA C- Family history of AAA is not a risk factor D- Screening for AAA has no impact on disease specific mortality E- All of the above are false

Abdominal Aortic Aneurysm • AAA >3.0 cm 6% at 65yo – Increases 6%/decade – 90% smokers – Ehlers Danlos, Marfans – Familial (30%, 6%) • Obvious risk=rupture – 90% mortality! 9K deaths – 2-6% operative mortality 1400-2800 deaths Aorta Rupture www.pennhealth.com/ int_rad/health_info/aaa.html

When to repair a AAA?? Surgical benefit>>Surgical risk when aneurysm is 5.5-6cm >1cm expansion/12mos Powell et al. NEJM 348;19, May 8, 2003

How to repair a AAA? DREAM Trial- >5 cms (Dutch Randomized EVR Aneurysm Trial) 345 patients Open-174 EVR-171 4.6% (8) 1.2% (2) Mortality 9.8% (17) 4.7% (8) Mortality or severe complications @30 days www.marketwire.com/ mw/release_html_b1?release... NEJM 351;16, Oct 14, 2004