More on atrial fibrillation & anticoagulation

Excellent review article on the newer anticoagulants for stroke and systemic embolism reduction in AF:

ACP Journal Club 18 Sept 2012

 

The CHA₂DS₂-VASc score identifies those patients with atrial fibrillation and a CHADS₂ score of 1 who are unlikely to benefit from oral anticoagulant therapy 

European Heart Journal Oct 2012

 

Various risk stratification schemes predict ischemic stroke and bleeding in atrial fibrillation

ACP Journal Club 16 Oct 2012

Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J. 2012;33:1500-10.

The CHA₂DS₂-VASc score had 100% sensitivity and 6% specificity for predicting stroke in patients with atrial fibrillation; CHADS₂ and Framingham scores had slightly lower sensitivities but higher specificities.

Commentary: In their analysis of 7 risk stratification schemes, Friberg and colleagues found that CHADS_2, CHA₂DS₂-VASc, and Framingham were the most accurate for predicting ischemic stroke, with c-statistics of 0.66 to 0.67. They also concluded that the 2 risk stratification schemes for bleeding had “similar predictive value,” but HEMORR₂HAGES had a higher c-statistic than the HAS-BLED scheme in 7 of 8 subgroups and the same value in 1 subgroup. A new risk stratification scheme, ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), was not evaluated (1).

Warfarin-associated major hemorrhage predicted by 7 risk stratification schemes in patients with atrial fibrillation
ACP Journal Club 15 Nov 2011

The ATRIA risk score has the potential to be a major clinical tool but needs further validation in other populations and comparisons with similar risk scores, such as HAS-BLED (2).

 ATRIA risk score had a similar c-statistic (0.69) to HEMORR2HAGES (0.67).

 

Patients at High Risk for Falls: A Reason Not to Anticoagulate?
(from Journal Watch)

Donzé J et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med 2012 Aug; 125:773

Among patients taking anticoagulants, high risk for falls was not associated with elevated risk for major bleeding.
Despite the proven benefits of oral anticoagulants in preventing and treating certain cardiovascular and cerebrovascular diseases, they are underprescribed. Fear of falls is the most commonly cited reason. Prior studies suggest that high fall risk should not be a contraindication to oral anticoagulant use, but these studies were limited by retrospective design or exclusion of patients at high risk for falls.
Researchers evaluated whether fall risk is associated with risk for major bleeding in a prospective study of 515 patients (median age, 71) who were treated with vitamin K antagonists at a hospital in Switzerland. Patients were considered to be at high risk for falls if they answered yes to either of two validated questions: (1) Did you fall during the last year? (2) Did you notice any problem with gait, balance, or mobility? Sixty percent of patients were categorized as high risk and all others as low risk. Times to first major bleeding event (including fatal or intracranial) within the 12-month follow-up did not differ significantly between the groups. Polypharmacy was associated independently with risk for major bleeds, with a 12% increase in risk for each additional drug taken.
Comment: This study adds to evidence that patients should not be denied oral anticoagulation solely on the basis of high risk for falls. For patients with valid indications for anticoagulation, benefit generally outweighs risk. For example, an analytic model suggests that older patients (age, 65) who have a 5% annual risk for stroke (i.e., CHADS₂ score of 2–3) and are taking anticoagulants would need to fall approximately 295 times yearly for risks of fall-related subdural hemorrhages to outweigh benefits of stroke prevention (Arch Intern Med 1999; 159:677). In addition, providers should be aware of risks conferred by polypharmacy in patients taking anticoagulants and should discontinue unnecessary medications, monitor patients more closely, or both.

CHF Prognostication

I favor the model described by Lee et al in the following study:

Predicting Mortality Among Patients Hospitalized for Heart Failure

JAMA.2003;290(19):2581-2587.

ACP Journal Club Commentary.

The actual risk prediction tool uses easily obtained variables (e.g. Age • Respiratory rate • Systolic blood pressure • Blood urea nitrogen • Serum sodium • Comorbid conditions: cerebrovascular disease, dementia, chronic obstructive pulmonary disease, cirrhosis, cancer, anemia) and the 30d. and 1 year risk score can be computed online:

http://www.ccort.ca/Research/CHFRiskModel.aspx

It has also been validated in populations in the US. 

Risk categories (score)	30-day mortality rate		1-year mortality rate
	Derivation	Validation	Derivation	Validation
Very low ( 60)	0.4%	0.6%	7.8%	2.7%
Low (61 to 90)	3.4%	4.2%	12.9%	14.4%
Intermediate (91 to 120)	12.2%	13.7%	32.5%	30.2%
High (121 to 150)	32.7%	26.0%	59.3%	55.5%
Very high (> 150)	59.0%	50.0%	78.8%	74.7%

A more recent article uses the same model to provide a median survival based on the risk scores above:

Life expectancy after an index hospitalization for patients with heart failure: a population-based study.

Am Heart J. 2008 Feb;155(2):324-31. PubMed PMID:18215604.

  

Table II. Mortality and life expectancy for all patients with HF according to the EFFECT HF risk score

	No. of patients	1-y mortality, n (%)	5-y mortality, n (%)	Median survival		Median survival for patients who survived first 3 m after hospitalization
				Months	95% CI	Months	95% CI
All patients with HF	9943	3294 (33.1%)	6833 (68.7%)	29	28-30	41	40-43
Baseline risk⁎
Very low	490	41 (8.4%)	117 (23.9%)	NA	NA	NA	NA
Low	3101	502 (16.2%)	1573 (50.7%)	59	55-62	66	63-71
Intermediate	4225	1450 (34.3%)	3185 (75.4%)	25	24-27	33	32-35
High	1770	1034 (58.4%)	1618 (91.4%)	8	7-9	18	17-20
Very high	357	267 (74.5%)	340 (95.2%)	3	2-4	12	10-15

NA, Not available.

Table IV. Mortality and life expectancy for patients with HF who had LVEF of ≤30% according to the EFFECT HF risk score

	No. of patients, n	1-y mortality, n (%)	5-y mortality, n (%)	Median survival		Median survival for patients who survived first 3 m after hospitalization
				Months	95% CI	Months	95% CI
All patients	1,467	489 (33.3%)	966 (65.8%)	31	27-35	46	42-49
Baseline risk⁎
Very low	131	16 (12.2%)	32 (24.4%)	NA	NA	NA	NA
Low	498	89 (17.9%)	252 (50.6%)	59	51-67	66	60-NA
Intermediate	559	207 (37.0%)	423 (75.7%)	22	19-27	32	28-36
High	225	140 (62.2%)	210 (93.3%)	6	4-9	18	14-21
Very high	54	37 (68.5%)	49 (90.7%)	3	2-8	14	7-24

 

Also useful is the EPERC FAST FACTS on CHF Prognostication and the Readmission Risk Calculator for CHF (also includes MI and Pneumonia).

The Central Role of Prognosis in Clinical Decision Making

JAMA Network | JAMA: The Journal of the American Medical Association | The Central Role of Prognosis in Clinical Decision Making

Physicians should be trained to consider prognosis in their clinical decision making. As a starting point, age-, sex-, and race-specific life expectancies (median and interquartile range) can be calculated using data from standard life tables.
Physicians could then make qualitative judgments, based on information from the medical record or clinical assessment, about whether a patient is likely to live substantially longer or shorter than an average person in his or her age and race cohort. The strongest and most consistent predictors of mortality in older persons include comorbidity and functional status. Lung disease requiring regular use of corticosteroids or supplemental oxygen, New York Heart Association class III or IV congestive heart failure, renal disease requiring dialysis, advanced dementia, inability to walk more than a block, and need for personal assistance with bathing are examples of factors that would reduce life expectancy substantially below the average.
The absence of significant comorbid conditions or functional limitations would identify older persons who are likely to live longer than average.

Antipsychotics and Mortality in Dementia

PsychiatryOnline | American Journal of Psychiatry | Antipsychotics and Mortality in Dementia
Commentary on Kales study Am J Psychiatry 2012;169:71-79

The study examined the relative risk of mortality associated with newly commenced prescriptions of olanzapine, quetiapine, and haloperidol, compared with risperidone as the reference compound, in a cohort of more than 30,000 veterans with dementia, ages 65 years and older.

Which antipsychotic has the highest and lowest risk of mortality?

Haloperidol was associated with significantly greater mortality than risperidone (relative risk=1.54).
Several studies have suggested that haloperidol confers a greater mortality risk than atypical antipsychotics (9), but the Kales et al. report is one of the few to have systematically compared mortality risk between different atypical antipsychotic agents.
Olanzapine and risperidone had similar mortality risk, while the risk for quetiapine was significantly lower (relative risk=0.73).
A key observation is that the highest increase in mortality risk was in the first 120 days, particularly in the first 30 days for haloperidol.

Which antipsychotic is best for aggression, agitation, or psychosis?

...three randomized controlled trials of quetiapine did not demonstrate any effectiveness in the treatment of aggression, agitation, or psychosis (4, 5).
The best evidence of efficacy is for risperidone, with consistent evidence of a modest but significant benefit over 12 weeks in the treatment of both aggression and psychosis.
There is also evidence of a similar level of benefit with aripiprazole, olanzapine, and haloperiodol, but only a few studies have examined other agents.
Through balancing the mortality data from this study and efficacy data from previous randomized controlled trials, risperidone and olanzapine emerge as the best evidence-based options.

What harms are associated with antipsychotic use?

...extrapyramidal symptoms, sedation, gait disturbances, and falls.
Many agents also lead to anticholinergic side effects, including delirium (4).
Tardive dyskinesia with atypical antipsychotics appears to occur less frequently than with typical antipsychotics, but QTc prolongation has been reported as a significant problem associated with several atypical antipsychotics.
A meta-analysis also identified a significant increase in respiratory and urinary tract infections as well as peripheral edema in people treated with risperidone, compared with placebo (4). These are likely to be class effects of atypical antipsychotics.
It has also become clear that other, more serious adverse outcomes, such as stroke and related cerebrovascular events, accelerated cognitive decline, and death, are significantly increased in people with dementia who are prescribed antipsychotics, compared with people with dementia not treated with these agents.
Deaths related to bronchopneumonia, thrombo-embolic events (including stroke and pulmonary embolism), and sudden cardiac arrhythmias are all significantly increased in people with dementia receiving antipsychotic treatment (6).
...meta-analyses of randomized controlled trials have reported significant incidence of sedation, chest-infection, and dehydration (4)

1.5- to 1.7-fold increase in mortality risk for people with Alzheimer's disease receiving antipsychotics

What can we do to reduce the harms associated with antipsychotic use?

...monitoring fluid intake and promoting vigilance for early detection and treatment of chest infections, may offer important potential opportunities to reduce excess mortality.
The potential role of ECG monitoring for prolonged QTc interval should perhaps also be considered

What about the use of non-psychotics like valproic acid?

The mortality risk for valproic acid and its derivatives, which were included as a nonantipsychotic comparison, was generally higher than the risk for quetiapine and similar to that for risperidone.

See guidelines below from UK Alzheimer's Society:

Optimising treatment and care for behavioural and psychological symptoms of dementia: A best practice guide

Obesity Counseling in Primary Care

Articles from NEJM

A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice 

by Wadden et al.

Practice Based Opportunities for WEight Reduction (POWER) Trial at Penn.
Enhanced weight-loss counseling (quarterly PCP visits combined with brief monthly sessions with lifestyle coaches who instructed participants about behavioral weight control PLUS meal replacements or weight-loss medication (orlistat or sibutramine)) helps about one third of obese patients achieve long-term, clinically meaningful weight loss.

Comparative Effectiveness of Weight-Loss Interventions in Clinical Practice

by Appel et al.

In two behavioral interventions, one delivered with in-person support and the other delivered remotely, without face-to-face contact between participants and weight-loss coaches, obese patients achieved and sustained clinically significant weight loss over a period of 24 months.

Obesity Treatment in Primary Care — Are We There Yet?

Editorial by Dr. Yanovski

Wadden study: "Although weight loss in the brief-lifestyle-counseling group (2.9 kg) and the usual-care group (1.7 kg) did not differ significantly at 2 years, participants in the enhanced-lifestyle-counseling group lost significantly more weight (4.6 kg) than did those in either of the other two groups and were more likely to lose at least 5% of their initial body weight (35% in the enhanced-lifestyle-counseling group, vs. 26% in the brief-lifestyle-counseling group and 22% in the usual-care group)."

Appel study: "Weight loss at 2 years was similar in the groups that received in-person support (5.1 kg) and remote support (4.5 kg) and was significantly greater than the weight loss in the control group (0.8 kg). Participants assigned to either the in-person or the remote lifestyle intervention were twice as likely as those assigned to the control group to have lost 5% or more of their initial body weight at 2 years (41% for the in-person group and 38% for the remote group, vs. 19% for the control group)."

"A well-recognized issue that affects the sustainability of behavioral interventions is that attendance at face-to-face counseling sessions decreases substantially over time."

"Given that remotely delivered coaching resulted in weight-loss outcomes similar to those of in-person visits, the use of mobile technologies to deliver behavioral weight-loss treatment in primary care appears to be promising. Such interventions may present fewer barriers to adherence than interventions delivered in person, since they allow for greater scheduling flexibility, decreased travel time, and lower transportation costs. In addition, a telephone-based coaching program has the potential for widespread implementation in multiple practice settings, including geographically isolated areas."

"Determining the costs and cost-effectiveness of these and other treatments in primary care settings is crucial. In addition, these two studies were not powered to detect differences in cardiovascular risk reduction, and there were no consistent between-group differences with respect to lipid levels, glucose levels, or blood pressure at 2 years."

MEDICARE COVERS SCREENING AND COUNSELING FOR OBESITY

The services will be free to beneficiaries — the Medicare deductible and co-pay will not apply.

(From Medscape) Medicare patients are eligible for "intensive behavioral therapy for obesity" from primary care providers — nonphysicians included — in a primary care setting if their body mass index (BMI) is 30 kg/m2 or more. They are entitled to 1 face-to-face counseling visit each week for a month, followed by a face-to-face session every other week for an additional 5 months.

If a patient has lost at least 6.6 pounds during the first 6 months of counseling, he or she is entitled to an additional visit every month for another 6 months. For patients who fail to lose the required weight, "a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period," according to CMS.

Specific services reimbursable under Medicare include an obesity screening, an assessment of the patient's diet, and behavioral counseling and therapy to promote sustained weight loss through diet and exercise. This course of treatment does not include medications for losing weight. CMS noted that the US Preventive Services Task Force had omitted medication from its recommendation for obesity screening and therapy for adults because of concerns about adverse drug events and lack of evidence about patients maintaining their weight after they stop taking such medications.

It remains to be seen what Medicare will pay for obesity counseling. In a "decision memo" published online, CMS stated that it is in the process of establishing payment codes.

The Rain Stick

This insightful and truthful poem + commentary was shared with me by a medical student.

The Rain Stick (from Academic Medicine)

Upend the rain stick and what happens next

Is a music that you never would have known

To listen for. In a cactus stalk

Downpour, sluice-rush, spillage and backwash

Come flowing through. You stand there like a pipe

Being played by water, you shake it again lightly

And diminuendo runs through all its scales

Like a gutter stopping trickling. And now here comes

A sprinkle of drops out of the freshened leaves,

Then subtle little wets off grass and daisies;

Then glitter-drizzle, almost-breaths of air.

Upend the stick again. What happens next

Is undiminished for having happened once,

Twice, ten, a thousand time before.

Who cares if all the music that transpires

Is the fall of grit or dry seeds through a cactus?

You are like a rich man entering heaven

Through the ear of a raindrop. Listen now again.

By Seamus Heaney


Commentary by Dr. Connelly

"The Rain Stick contains secrets for all who want to, try to, and long to heal and care for others. The opening lines direct the reader toward a mystery that is not often acknowledged in medicine, the mystery of not-knowing. "

"True understanding requires the physician to follow the narrative thread, ask questions to clarify asides, and listen on many levels. Learning from The Rain Stick interested physicians could ask:

If I engage this patient from a perspective of not-knowing, how might I be surprised? If I am open, interested, curious about the patient, what might I understand about him or her or even myself?"

"The impression that patients are static objects is flawed. ... Heaney reminds us that no experience is routine or everyday. Each patient no matter how routine the symptom, as seen by the physician, holds a unique experience within."

"Who cares if all the music that transpires/Is the fall of grit or dry seeds through a cactus?

As judgments precede interactions, physicians become closed, not interested, not curious, not receptive, not caring. And in this diminished state, they do not see or hear the truth arising in the experience with the other."

"... many physicians fear being open and vulnerable with patients. Yet, a closer look at the fear may reveal a deep and personal misunderstanding. Fear does not require abandonment of self. This discomfort can easily be diminished by direct and real human contact as demonstrated by true listening such that the other feels heard and understood."

"Ultimately physicians may be able to share interpersonal lessons and kindness as well as nurturing the potential for personal growth, change, even transformation, if they are willing to-listen now again."

Discussing Overall Prognosis with the Very Elderly — NEJM

Discussing Overall Prognosis with the Very Elderly — NEJM

Perspective article.

"offering to discuss overall prognosis with very elderly patients should be the norm, not the exception."

"We would suggest that clinicians should routinely offer to discuss the overall prognosis for elderly patients with a life expectancy of less than 10 years, or at least by the time a patient reaches 85 years of age. By that age, the average remaining life expectancy in the United States is 6 years; 85-year-old Americans have a 75% chance of living 3 more years and a 25% chance of living 10 more years"

"For patients with a life expectancy of more than 10 years, cancer screening, intensive blood-pressure management, and tight control of glycated hemoglobin levels will have high priority, whereas for patients with a shorter life expectancy, priority might be given to reducing the pill burden and engaging in advance care planning."

"Avoiding burdensome and potentially risky interventions of limited benefit may improve a patient's functional abilities and quality of life."

"a majority of elderly patients (65%) might want to discuss prognosis, whereas a substantial minority might not. Clinicians should therefore offer to discuss overall prognosis with very elderly patients — but respect those who decline."

See Table: Common Medical Decisions and Life Choices That Offer Opportunities to Discuss Overall Prognosis with Very Elderly Patients.

"To make care more patient-centered, we need to start helping our very elderly patients set goals of care that take their overall prognosis into account. We should do so in the ordinary course of clinical practice, letting our patients be our guides."