American College of Physicians: Internal Medicine — Doctors for Adults ®


In the News
for the Week of 4-21-09


  • CAD screening not worthwhile for asymptomatic diabetics
  • Valsartan doesn’t help reduce recurrent atrial fibrillation
  • ACP Internist delivers daily updates from Internal Medicine 2009

Test yourself

  • MKSAP quiz: appropriate medication change for diabetes


  • Statins reduce initial, recurrent strokes, review finds
  • Aspirin, carbasalate calcium may have different effects on cerebral microbleeds

Mental health

  • PCPs have trouble getting outpatient mental health services for patients

Annals of Internal Medicine

  • Patient-tailored treatments may matter more than strict glycemic control

FDA update

  • Influend Cough and Cold products recalled
  • Patients older than 28 days can use ceftriaxone with calcium

From ACP Internist

  • Cartoon caption contest: Vote for your favorite entry
  • Tweet the meet: Twittering from Internal Medicine 2009
  • Correction to "Adult Immunization News"

From ACP Hospitalist

Editor's note: ACP Internist Weekly readers will receive daily updates from Internal Medicine 2009 in Philadelphia April 23-25. There will be no issue on April 28.

Physician editor: Darren Taichman, ACP Member


CAD screening not worthwhile for asymptomatic diabetics

Screening for coronary artery disease does not improve outcomes in asymptomatic patients with type 2 diabetes, according to a new study.

The trial included 1,123 diabetic patients who were randomized to screening with adenosine-stress radionuclide myocardial perfusion imaging (MPI) or no screening. Follow-up ran from August 2000 to September 2007, with an average of 4.8 years. No significant differences were found in outcomes between the two groups: seven nonfatal myocardial infarctions (MI) and eight cardiac deaths occurred in the screened group, compared with 10 MIs and seven deaths in the unscreened group.

The study found that the discovery of significant MPI abnormalities in screening was associated with cardiac events, but the positive predictive value was low (12% for moderate or large defects). Overall, the cumulative cardiac event rate for the whole study population was only 2.9%. The research was published in the April 15 Journal of the American Medical Association.

Based on the results, the study authors recommended against routine screening for inducible ischemia in asymptomatic patients with type 2 diabetes for four reasons:

  • The yield of detected ischemia was relatively low;
  • The overall event rate was low;
  • Routine screening did not affect overall outcomes; and
  • Screening would be prohibitively expensive.

However, on the positive side, the authors noted that patients such as those in the study population appear to already have relatively favorable outcomes, according to the trial's findings.


Valsartan doesn’t help reduce recurrent atrial fibrillation

Treatment with valsartan (Diovan) doesn't appear to reduce the incidence of recurrent atrial fibrillation, a new study found.

Researchers randomized to placebo or valsartan 1,442 patients age 40 or older who'd had either two or more documented episodes of atrial fibrillation in the last six months, or successful cardioversion for atrial fibrillation in the previous two weeks. Patients also had to have underlying cardiovascular disease, diabetes or left atrial enlargement; and had to have been in sinus rhythm for at least two days before randomization. The study drug began at 80 mg daily for two weeks then was increased to 160 mg daily for the next two weeks. At four weeks, the dose was increased to 320 mg and remained there until the end of follow-up at 52 weeks.

Atrial fibrillation recurred in 51.4% of the valsartan subject and 52.1% of the placebo group, a nonsignificant difference. More than one episode of atrial fibrillation occurred in 26.9% of the valsartan group and 27.9% of the placebo group. Results were similar in all pre-established subgroups. The study was published in the April 16 New England Journal of Medicine.

The trial may have been limited by its comparatively short one-year follow-up period; on the other hand, there was no trend supporting valsartan therapy to suggest more time could have changed the outcome, the authors said. Also, the results of the study can't be extrapolated to patients with heart failure or left ventricular systolic dysfunction, as only 8% of study subjects had either of these conditions, and past studies have suggested ACE inhibitors or ARBs are of particular help to this subgroup, an editorial noted.


ACP Internist delivers daily updates from Internal Medicine 2009

Look for special ACP Internist coverage from Internal Medicine 2009 with daily e-mail alerts from April 23-25. Coverage includes recaps for those not attending and alerts of upcoming events for those at the meeting. Look for events in your e-mail inbox or follow us online and on our blog.


Test yourself

MKSAP quiz: appropriate medication change for diabetes

A 54-year-old man was recently diagnosed as having type 2 diabetes mellitus. He has been treated for hyperlipidemia and hypertension for the past 2 years. He does not have known cardiovascular disease. His current medications are metformin 1000 mg twice a day, pioglitazone 15 mg/d, lisinopril 20 mg/d, atorvastatin 20 mg/d, and aspirin 325 mg/d.

On physical examination the blood pressure is 120/75 mm Hg, pulse rate 84/min, and BMI 29.6.

Laboratory Studies

Fasting glucose 159 mg/dL (8.82 mmol/L)
Hemoglobin A1C 7.4%
Creatinine 1.1 mg/dL (97.26 μmol/L)
Cholesterol 142 mg/dL (3.67 mmol/L)
Triglycerides 145 mg/dL (1.64 mmol/L)
HDL cholesterol 48 mg/dL (1.24 mmol/L)
LDL cholesterol 65 mg/dL (1.68 mmol/L)
Urine microalbumin/creatinine 13

In addition to emphasizing diet, exercise, and weight loss, what would be the most appropriate medication change at this time?

A) Add a fibrate
B) Add niacin
C) Increase lisinopril dose
D) Increase atorvastatin dose
E) Increase pioglitazone dose

Click here or scroll to the bottom of the page for the answer and critique.



Statins reduce initial, recurrent strokes, review finds

Statins are effective in reducing initial and recurrent stroke, and may reduce other cardiovascular events in patients with non-cardioembolic stroke regardless of ischemic stroke subtypes, according to a recent meta-analysis.

The meta-analysis of 24 studies incorporating 165,792 individuals in randomized trials of statins in combination with other preventive strategies, shows that each 1 mmol/L (39 mg/dL) decrease in LDL cholesterol reduces the relative risk of stroke by 21.1% (95% confidence interval [CI] 6.3-33.5, P=0.009). Statins' protective effect appeared to be primarily linked to LDL cholesterol lowering, the study found, triglyceride-lowering therapy with fibric acid compounds, or their combination with statins, and treatments to raise HDL cholesterol might also decrease the residual risk of stroke. Researchers reported findings in The Lancet Neurology.

Intense reduction of LDL cholesterol by statins significantly reduced the risk of recurrent stroke (relative risk [RR] 0.84, 0.71-0.99, P=0.03) and major cardiovascular events (0.80 RR, 0.69-0.92, P=0.002) for secondary prevention of non-cardioembolic stroke. Statins also slow the progression of carotid artery blockage, reduce inflammation and endothelial dysfunction, decrease platelet aggregation, improve fibrinolysis, lower blood pressure, and decrease the risk of thromboembolic complications to the brain by reducing the incidence of heart attacks.

But, the authors wrote, because of increased incidence of hemorrhagic stroke seen in two previous studies (SPARCL: Stroke Prevention by Aggressive Reduction of Cholesterol Levels, and the Heart Protection Study), they recommend caution when considering statin therapy in patients with prior cerebral haemorrhage. Pending further data from other secondary prevention trials in patients with stroke, they added, statins should be used only for patients at high risk of major coronary or other atherothrombotic events, and not for aggressive cholesterol reduction. Reviewers called for studies comparing LDL targets, for example, less than 2.6 mmol/L (100 mg/dL) and less than 1.8 mmol/L (70 mg/dL) after stroke.


Aspirin, carbasalate calcium may have different effects on cerebral microbleeds

There's a higher prevalence of strictly lobar cerebral microbleeds among those taking aspirin than carbasalate calcium, according to researchers in the Netherlands.

To investigate the relation between antithrombotic drug use and cerebral microbleeds in strictly lobar locations—considered an indicator for cerebral amyloid angiopathy—researchers conducted a population-based, cross-sectional analysis of 1,062 people. Platelet aggregation inhibitor and anticoagulant drug use was obtained from pharmacy records. The primary outcome was the presence of cerebral microbleeds as assessed by magnetic resonance imaging. Researchers published the full results online in Archives of Neurology.

Cerebral microbleeds occurred more often among those who'd taken platelet aggregation inhibitors than nonusers (adjusted odds ratio [OR], 1.71; 95% confidence interval [CI], 1.21-2.41). Strictly lobar microbleeds were more prevalent among aspirin users (adjusted OR compared with nonusers, 2.70; 95% CI, 1.45-5.04) than among those taking carbasalate calcium (adjusted OR, 1.16; 95% CI, 0.66-2.02). This difference was even more pronounced when comparing people who had used similar dosages of both drugs.

Researchers emphasized that because this was a cross-sectional study and not a randomized clinical trial, "It may be that in selected persons (eg, those with signs of cerebral amyloid angiopathy), this risk-benefit ratio may differ for certain drugs (eg, aspirin), thus influencing treatment decisions."


Mental health

PCPs have trouble getting outpatient mental health services for patients

Sixty-seven percent of primary care providers were unable to get outpatient mental health services for their patients in 2004-05, a new survey found.

Specifically, the survey of 2,900 internists, family practitioners and pediatricians cited health plan barriers, lack of or inadequate insurance coverage, and shortages of mental health providers as common reasons their patients couldn't get mental health care. By comparison, 34% reported being unable to get specialist referrals, 30% were unable to get diagnostic imaging, and 17% couldn't get nonemergency hospital admissions. The survey was conducted by the Center for Studying Health System Change, funded by the Commonwealth Fund, and published in the April 14 Health Affairs.

Survey data was collected before passage of the 2008 Mental Health Parity and Addiction Equity Act, which requires mental health parity in most private insurance plans. Still, the study found existing state parity laws had only a modest effect on reducing disparities in access to mental health care. Primary care providers in states with mandatory parity were eight percentage points less likely to report problems due to health plan barriers, and five percentage points less likely to report problems from lack of or inadequate insurance coverage. They were more likely to report problems with a shortage of providers, though this result wasn't statistically significant.

Even with national parity legislation, gaps in mental health access will likely remain, particularly in the area of provider shortages, the article concluded.


Annals of Internal Medicine

Patient-tailored treatments may matter more than strict glycemic control

Researchers reviewed large trials that randomized type 2 diabetic patients to either tight or loose targets for glycemic control. Physicians should support healthy lifestyles, preventive care, and cardiovascular risk reduction, as well as individualize drug treatment approaches so that patients can aim for a blood glucose level that best balances the burden of medication with the benefit in reducing symptoms and complications of diabetes. The authors advocate for tools and tactics that encourage patient involvement in treatment decisions, as these may lead to treatment programs that are both evidence-based and consistent with patients’ lifestyles and informed values. This early release article will appear in the June 2 print edition.

Also from the Annals of Internal Medicine

  • Universal insurance may reduce race-based disparities. Researchers studied National Health and Nutrition Examination Survey data collected from 1998 to 2006 on more than 9,000 adults with chronic conditions such as hypertension, diabetes, or coronary heart disease. They assessed chronic disease control measurement, compared patients by race, ethnicity, and education, and then considered Medicare eligibility. While control of hypertension, diabetes and coronary heart disease improved over the years, racial disparities didn't. However, the gaps narrowed after age 65 when Medicare insurance begins.
  • USPSTF recommendations to prevent tobacco use. The U.S. Preventive Services Task Force reaffirmed its 2003 recommendation that clinicians should ask all adults about tobacco use and provide tobacco cessation interventions. For pregnant women, clinicians should ask about tobacco use and provide pregnancy-tailored counseling for those who smoke.
  • Genetic and other risk factors for type 2 diabetes. Researchers sought to determine if combining genetic screening with an assessment of conventional risk factors could help physicians identify high-risk populations. Two cohorts of European ancestry were used to developing a genetic risk score that combined data on 10 diabetes-related mutations. While genetic testing in combination with conventional risk factors identifies subgroups of a population with a particularly high risk for type 2 diabetes, clinical predictions plus genetic test results were only slightly better than using only conventional risk factors.


FDA update

Influend Cough and Cold products recalled

ION Labs, Inc. is recalling Influend Cough and Cold products sold on or after May 30, 2008 because they may be more potent than intended, the FDA said last week.

Complications from the recalled products could include tachycardia, palpitations, arrhythmias, cardiovascular collapse with hypotension, dizziness, anxiety, headache and nervousness. No illnesses have been reported to date.

Products affected by the recall include the 24-tablet Influend Cold and Cough (Lot#800074) and Influend Severe Cold & Flu (Lot# 800075); and the 4-oz. bottle of Influend JR. Cold & Cough (Lot# 800076) and Influend JR. Severe Cold & Flu (Lot# 800077).


Patients older than 28 days can use ceftriaxone with calcium

Ceftriaxone (Rocephin) can be used concomitantly with intravenous calcium-containing products in patients older than 28 days, the FDA said last week in an update.

The FDA had warned physicians in 2007 against administering calcium-containing products and ceftriaxone within 48 hours of each other due to a risk for precipitation of ceftriaxone-calcium. Based on the results of two in vitro studies conducted by manufacturer Roche, the agency has now determined this risk is low in patients more than 28 days old.

Ceftriaxone should still not be used in neonates younger than 28 days if they are receiving, or are expected to receive, calcium-containing intravenous products. In patients older than this, the two products may be administered sequentially, as long as the infusion lines are thoroughly flushed between infusions with a compatible fluid, the FDA said.


From ACP Internist

Cartoon caption contest: Vote for your favorite entry

The cartoon caption contest goes on the road this week, with the winner being announced in our meeting coverage from Internal Medicine 2009. Vote by Friday, April 24 for your favorite caption from among the finalists here and then find out who won in the Saturday e-mail edition of our coverage.


Tweet the meet: Twittering from Internal Medicine 2009

ACP will Twitter from Internal Medicine 2009. Join us at And Vineet Arora, FACP, will use her Twitter feed to digest events from Internal Medicine 2009. Using the alias @FutureDocs, she usually sends tweets about medical education for students and residents. Subscribe, or check out her Twitter page.


Correction to "Adult Immunization News"

"Adult Immunization News," which appears on page 20 in the April 2009 ACP Internist, was incorrectly labeled as an advertisement. The article was prepared by ACP staff and supported by unrestricted educational grants from Sanofi-Pasteur and Merck Vaccines.


From ACP Hospitalist

Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our second annual Top Hospitalists issue. We're looking for the hospitalists who made notable contributions to the field in 2009, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement.

Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 13, 2009, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2009 issue.


MKSAP answer and critique

The correct answer is E) Increase pioglitazone dose. This item is available to MKSAP 14 subscribers in the Endocrinology section, item 38.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To order the latest edition of MKSAP, go online.

The current American Diabetes Association (ADA) recommended goals for management of adults with diabetes are as follows: hemoglobin A1C <7.0%, preprandial plasma glucose 90-130 mg/dL (5-7.22 mmol/L), peak (2 hour) postprandial plasma glucose <180 mg/dL (9.99 mmol/L), blood pressure <130/80 mm Hg, triglycerides <150 mg/dL (1.69 mmol/L), HDL cholesterol >40 mg/dL (1.03 mmol/L), and LDL cholesterol <100 mg/dL (2.59 mmol/L) (but <70 mg/dL [1.81 mmol/L] may be considered). Since this patient has a hemoglobin A1C of 7.4% and he is taking the lowest available dose of pioglitazone, the most appropriate change is to increase his pioglitazone dose. His blood pressure, serum triglycerides, serum LDL cholesterol, and serum HDL cholesterol are all below the recommended goal and therefore adding a fibrate or niacin or increasing the doses of lisinopril or atorvastatin are not necessary at this time.

Key Point

  • The ADA recommended goals for management of adults with diabetes are hemoglobin A1C <7.0%, preprandial plasma glucose 90-130 mg/dL (5-7.22 mmol/L), peak (2 hour) postprandial plasma glucose <180 mg/dL (9.99 mmol/L), blood pressure <130/80 mm Hg, triglycerides <150 mg/dL (1.69 mmol/L), HDL cholesterol >40 mg/dL (1.03 mmol/L), and LDL cholesterol <100 mg/dL (2.59 mmol/L).

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Copyright 2009 by the American College of Physicians.


Test yourself

A 38-year-old woman is evaluated during a follow-up visit. She has a history of well-controlled hypertension and type 1 diabetes mellitus. She is at 16 weeks' gestation with her first pregnancy. Prior to conception she was taking lisinopril, which was discontinued in anticipation of the pregnancy, and labetalol was initiated. Other medications are insulin glargine, insulin lispro, and a prenatal vitamin. Following a physical exam and lab studies, what is the most appropriate step in the management of this patient's hypertension? .

Find the answer

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