T HE T OP 5 P APERS OF 2017 Amol Verma MD MSc FRCPC Kieran Quinn MD - - PowerPoint PPT Presentation

THE TOP 5 PAPERS OF 2017

Amol Verma MD MSc FRCPC Kieran Quinn MD MSc FRCPC

• No Disclosures

TOP 5 PAPERS

• PFO closure in stroke
• PE in syncope
• Re-evaluating asthma diagnosis
• BNP-guided treatment in heart failure
• Opioid prescribing in ED

IS THAT A PFO SIGHTING?

CASE 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?”

THE BOTTOM LINE

• 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%

DISCUSSION

• 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

TAKE-HOME MESSAGE

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.

CASE 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?”

TO PE OR NOT TO PE

CASE 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?”

THE BOTTOM LINE

• 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

DIAGNOSTIC YIELD

(GEMINI V. PESIT)

BASELINE CHARACTERISTICS

• 24/97 (25%) had no signs or symptoms of

PE

TAKE-HOME MESSAGE

Syncope is a challenging diagnosis … …patients should receive systematic clinical assessment (Wells Score +/- investigations) for pulmonary embolism.

CASE 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?”

AIRWAY TODAY, GONE TOMORROW?

CASE 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?”

THE BOTTOM LINE

• 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

RESULTS

• 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
• n repeat testing:

– At least 16% negative to positive – At least 12% positive to negative

DISCUSSION

• Reason for change in asthma diagnosis:

– Misdiagnosis – Natural history of disease – Change in environmental exposures

• Limitations

– Selection bias – Mild-moderate asthma (less severe)

TAKE-HOME MESSAGE

• 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

CASE 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?”

DON’T STOP BNPIN’?

CASE 4

• 62M with HF for just over 1 year
• LVEF 25%, NYHA 2-3 with CAD and DM
• n 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?”

THE BOTTOM LINE

• In patients with chronic HFrEF, there was

no difference in time to first hospitalization

• r 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

TAKE-HOME MESSAGE

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!

CASE 4

• 62M with HF for just over 1 year
• LVEF 25%, NYHA 2-3 with CAD and DM
• n 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?”

“THE PATH TO DISCHARGE IS PAVED

WITH PERCOCET”

CASE 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?”

THE BOTTOM LINE

• 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

1.16% 1.51% 7.3% 24.1%

RESULTS

• NNH:

– 48 opioid prescriptions à 1 long-term user

• Small increase in opioid-related

hospitalizations

• No signs of ‘undertreatment’ in low-

intensity group

TAKE-HOME MESSAGES

• 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

CASE 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?”

THE TOP 5 PAPERS OF 2017

Amol Verma MD MSc FRCPC Kieran Quinn MD MSc FRCPC

SUPPLEMENTARY SLIDES

PFO

PFO

PFO

PFO

ASTHMA

ASTHMA

PESIT

PESIT

BNP

BNP

BNP

BNP

OPIOIDS

OPIOIDS

OPIOIDS