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

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ACP InternistWeekly



In the News for the Week of November 20, 2012




Highlights

ACP, other groups issue joint recommendations on stable ischemic heart disease

Two new clinical practice guidelines for diagnosing and treating stable ischemic heart disease (IHD) were released by a collaboration of medical organizations. More...

Lipid levels similar regardless of whether patients fast before testing

Lipid levels did not vary significantly depending on whether patients fasted before lipid profile testing, according to a recent study. More...


Test yourself

MKSAP Quiz: Cardiac risk reduction

A 62-year-old man is evaluated during a routine examination. Medical history is significant for a myocardial infarction 3 years ago, dyslipidemia, hypertension, tobacco use, and drinking two alcoholic drinks per day. What intervention offers the greatest cardiac risk reduction in this patient? More...


Cardiology

Clinical context should be considered when ordering, interpreting troponin test

Guidance on when to order and how to interpret a troponin level, in order to initiate appropriate treatment and to optimize outcomes, was offered last week by a new consensus document issued by six medical societies. More...


Patient-physician communication

Patients may overestimate benefits of screening programs, preventive medicines

Patients overestimated the risk reduction achieved with screening and preventive medications, and clinicians should keep that tendency in mind when discussing such issues with patients, a study found. More...

New ACP ethics case study available

ACP's case study "Stewardship of Health Care Resources: Responding to a Patient's Request for Antibiotics" is now available online through Medscape. More...

Inappropriate care requests: the role of health care professionals

Yul Ejnes, MD, MACP, immediate past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his column at KevinMD.com, one of the Web's leading destinations for provocative physician commentary. More...


Osteoarthritis

ACP supports Chronic Osteoarthritis Management Initiative

The College has lent its support to the Chronic Osteoarthritis Management Initiative coordinated by the U.S. Bone and Joint Initiative. More...


Education

Conference to be held on evidence-based guidelines

The Guidelines International Network North America and the Section on Evidence Based Health Care of the New York Academy of Medicine are sponsoring a conference, "Evidence-Based Guidelines Affecting Policy, Practice and Stakeholders (E-GAPPS)," to be held this December. More...


CMS update

Reminder of ACP webinar on PQRS requirements

ACP is hosting an informational webinar on the PQRS (Physician Quality Reporting System) reporting requirements for physicians on Nov. 29, 2012. More...


From ACP Hospitalist

The next issue of ACP Hospitalist is online

The November issue of ACP Hospitalist is now online, featuring its annual Top Docs. More...


From the College

College Master wins 2012 Flexner Award

Ruth-Marie (Rhee) Fincher, MD, MACP, has received the 2012 Abraham Flexner Award for Distinguished Service to Medical Education from the Association of American Medical Colleges. More...

College Fellow awarded Albert Schweitzer Prize for Humanitarianism

James J. O'Connell, MD, FACP, has been awarded the 2012 Albert Schweitzer Prize for Humanitarianism. More...


Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...

Editorial note: ACP InternistWeekly will not be published next week due to the Thanksgiving Day holiday.


Physician editor: Philip Masters, MD, FACP



Highlights


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ACP, other groups issue joint recommendations on stable ischemic heart disease

Two new clinical practice guidelines for diagnosing and treating stable ischemic heart disease (IHD) were released today by a collaboration of medical organizations.

The guidelines were issued by ACP, the American Association for Thoracic Surgery, the American College of Cardiology Foundation, the American Heart Association, the Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons and were published Nov. 20 by Annals of Internal Medicine and Journal of the American College of Cardiology.

annals.jpg

The recommendations in "Diagnosis of Patients with Stable Ischemic Heart Disease" address initial cardiac testing to diagnose stable IHD; cardiac stress testing to assess risk in patients with known stable IHD who are able to exercise, who are unable to exercise, and regardless of ability to exercise; coronary angiography as an initial testing strategy to assess risk in patients with stable IHD; and coronary angiography to assess risk after initial workup with noninvasive testing.

Because angina is often a symptom of stable IHD, the guidelines noted that patients with chest pain should receive a thorough history and physical examination to assess the probability of stable IHD prior to additional testing. Choices regarding diagnostic and therapeutic options should be made through a process of shared decision making between the patient and physician.

The guideline "Management of Patients with Stable Ischemic Heart Disease" addresses patient education, risk factor modification, medical therapy to prevent myocardial infarction and death, medical therapy and alternative therapy for relief of symptoms, revascularization, and patient follow-up.

Patients with stable IHD should have an individualized education plan to optimize care, including education on the importance of medication adherence, an explanation of cardiovascular risk reduction strategies, a description of appropriate levels of daily physical activity, and information on how to recognize worsening cardiovascular symptoms and take appropriate action.

The organizations recommended against several potential risk reduction strategies because of their unproven benefit for patients with stable IHD:

  • Estrogen therapy should not be initiated in postmenopausal women.
  • Vitamin C, vitamin E, and beta-carotene supplementation should not be used.
  • Elevated homocysteine should not be treated with folate and/or vitamins B6 and B12.

The above therapies may be indicated in people with other conditions, the guidelines noted. Aspirin therapy, in a 75- to 162-mg daily dose, should be continued indefinitely in the absence of contraindications in patients with stable IHD.

Patients with stable IHD should receive periodic follow-up at least annually that includes:

  • assessment of symptoms and clinical function;
  • surveillance for complications of stable IHD, including heart failure and arrhythmias;
  • monitoring of cardiac risk factors; and
  • assessment of the adequacy of and adherence to recommended lifestyle changes and medical therapy.

An accompanying editorial in Annals noted several surprising aspects to the guidelines, including recommendations for treadmill electrocardiography stress testing without imaging in women with intermediate-probability symptoms, which the editorialist said "may not match common clinical practice, but … probably should," and initial testing with stress imaging for all patients with prior revascularization, which the editorialist said "may not match current practice but makes good clinical sense, because it tells us not only if the chest pain is 'real,' but also how large a region of myocardium is at risk."


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Lipid levels similar regardless of whether patients fast before testing

Lipid levels did not vary significantly depending on whether patients fasted before lipid profile testing, according to a recent study.

Researchers used community-cohort laboratory data from Calgary, Canada, which included more than 200,000 people who had at least one lipid level tested and a fasting time recorded. Their mean total cholesterol level was 183.4 mg/dL, their high-density lipoprotein (HDL) level was 55.2 mg/dL, their low-density lipoprotein (LDL) level was 103.3 mg/dL and their triglyceride level was 127.6 mg/dL. Patients reported fasting times between 1 and 16 hours. Results were published by Archives of Internal Medicine on Nov. 12.

The study found that mean levels of total and HDL cholesterol didn't differ much according to fasting time. LDL cholesterol varied somewhat more, up to 10% across the range of fasting times. Mean triglycerides showed the greatest changes with fasting time, varying up to 20%. The study authors concluded that fasting times showed little association with lipid levels, indicating that routine recommendations for fasting may be unnecessary.

Fasting before testing causes a number of hassles, including inconvenience for patients, lower compliance with prescribed testing, and wait times at phlebotomy clinics, the authors noted. Based on this study and other recent research, they concluded that nonfasting testing is a reasonable alternative to fasting lipid testing, although patients who have a nonfasting triglyceride level of 400 mg/dL or higher should receive follow-up assessment.

An accompanying commentary agreed, although the author added high-risk patients such as diabetics to the list of those for whom nonfasting testing might not be appropriate. The commentary also pointed out several limitations to the study, including that most patients had fasted for at least nine hours, that the population was generally low-risk, and that the trial was not randomized. The authors of both the commentary and the study called for future research comparing fasting and nonfasting lipid levels in the same individuals.



Test yourself


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MKSAP Quiz: Cardiac risk reduction

A 62-year-old man is evaluated during a routine examination. Medical history is significant for a myocardial infarction 3 years ago, dyslipidemia, hypertension, tobacco use, and drinking two alcoholic drinks per day. Medications are an ACE inhibitor, a statin, a β-blocker, and aspirin. He participates in cardiac rehabilitation, exercising four to five times per week.

mksap.gif

On physical examination, he is afebrile, blood pressure is 128/80 mm Hg, pulse rate is 83/min, and respiration rate is 18/min. BMI is 31 kg/m2. The patient has an obese abdomen.

Laboratory studies show a serum LDL cholesterol level of 68 mg/dL (1.76 mmol/L), HDL cholesterol level of 43 mg/dL (1.11 mmol/L), and triglyceride level of 150 mg/dL (1.70 mmol/L).

Which of the following interventions offers the greatest cardiac risk reduction in this patient?

A: Increase physical activity
B: More aggressive blood pressure lowering
C: More aggressive lipid modification
D: Reduce alcohol consumption
E: Smoking cessation

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


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Cardiology


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Clinical context should be considered when ordering, interpreting troponin test

Guidance on when to order and how to interpret a troponin level, in order to initiate appropriate treatment and to optimize outcomes, was offered last week by a new consensus document issued by six medical societies.

Elevated troponin levels by themselves do not indicate myocardial infarction (MI, defined as myonecrosis due to ischemia), the document states. Troponin levels are nonspecific relative to the etiology of cardiac myonecrosis and occur in many nonischemic clinical conditions. As assays become more sensitive, more conditions that elevate troponin by even small amounts will be identified, the document continues.

The consensus document was developed in collaboration with the American College of Cardiology, American Association for Clinical Chemistry, American College of Chest Physicians, American College of Emergency Physicians, American Heart Association, and Society for Cardiovascular Angiography and Interventions.

The full report appeared online at the American College of Cardiology website and will be published in the Dec. 12 Journal of the American College of Cardiology.

The document also explains when a troponin level should be obtained.

  • Because it is not specific for MI, troponin evaluation should be performed only if clinically indicated for suspected MI.
  • An elevated troponin level must always be interpreted in the context of the clinical presentation and pre-test likelihood that it represents MI.
  • Troponin is recommended for diagnosis of MI in chronic kidney disease (CKD) patients with symptoms of MI (regardless of severity of renal impairment). Dynamic changes in troponin values of ≥20% over six to nine hours should be used to define acute MI in end-stage renal disease patients.
  • In the absence of specific interventions based on the results, routine troponin testing is not recommended for nonischemic clinical conditions. Two exceptions include Food and Drug Administration-approved troponin testing for prognosis in CKD patients and treating chemotherapy patients who have a drug-induced cardiac injury.

The consensus document also defines the prognostic significance of an elevated troponin level and provides at-a-glance resources for physicians, including a schematic of potential reasons for elevated troponin levels and flow diagrams to help clinicians determine when to use troponin in therapeutic decision making.



Patient-physician communication


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Patients may overestimate benefits of screening programs, preventive medicines

Patients overestimated the risk reduction achieved with screening and preventive medications, and clinicians should keep that tendency in mind when discussing such issues with patients, a study found.

To assess patients' expectations about screening and prevention, researchers surveyed them about the benefits of screening for breast and bowel cancer, as well as drugs to prevent hip fracture and cardiovascular disease. Researchers mailed questionnaires to all registered patients ages 50 to 70 years from among the panels of three general practitioners in Christchurch, New Zealand.

The questionnaire examined expectations of benefit for four specific preventive measures: a breast cancer screening program already offered in New Zealand, a bowel cancer screening in a pilot phase in one region of the country, and treatment with preventive medications for cardiovascular disease and hip fracture. Results appeared in the November/December Annals of Family Medicine.

The questionnaire asked participants to select how many deaths or fractures would be avoided in a group of 5,000 people ages 50 to 70 years undergoing the specific interventions for 10 years: 1, 5, 50, 100, 500, or 1,000. Responses were then compared to the actual expected benefits of the studied interventions. Next, the questionnaire asked the study population to indicate the minimum number of lives saved or hip fractures prevented they believed might justify the intervention.

Of 977 patients invited, 354 (36%) completed the questionnaire. Among the four scenarios, 90% of participants overestimated the effect of breast cancer screening, 94% overestimated the effect of bowel cancer screening, 82% overestimated the effect of medicine to prevent hip fracture, and 69% overestimated the effect of medication to prevent cardiovascular disease.

Most respondents also set their minimum benefit that would justify the interventions higher than what the treatments actually achieve. Cardiovascular disease prevention was the one exception to this finding. Although the study was performed outside the United States and the response rate to the survey was relatively low, the results suggest that the tendency to overestimate benefits may affect patients' decisions to adopt such preventive interventions, and practitioners should be aware of this when talking to patients, the researchers noted.

"[D]octors should be aware that many patients have overly optimistic expectations of the benefits of preventive interventions and screening," the authors wrote. "This misperception may impair informed decision making about the use of such interventions, and physicians should consider using decision aids with patients when discussing these interventions."


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New ACP ethics case study available

ACP's case study "Stewardship of Health Care Resources: Responding to a Patient's Request for Antibiotics" is now available online through Medscape.

The case study examines the ethical issues arising for the physician in response to a patient's request for nonbeneficial treatment. Developed with funding from the American Board of Internal Medicine Foundation as part of the ABIMF's Putting the Charter into Practice initiative, the case study is part of a series that uses hypothetical examples to elaborate on controversial or subtle aspects of issues not addressed in ACP's Ethics Manual, the Physician Charter on Professionalism, or other College position statements. More information and access to the case study are online.


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Inappropriate care requests: the role of health care professionals

Yul Ejnes, MD, MACP, immediate past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his column at KevinMD.com, one of the Web's leading destinations for provocative physician commentary. In this month's post, Dr. Ejnes offers suggestions about how health care professionals can work together to reduce unnecessary tests and treatments.



Osteoarthritis


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ACP supports Chronic Osteoarthritis Management Initiative

The College has lent its support to the Chronic Osteoarthritis Management Initiative coordinated by the U.S. Bone and Joint Initiative.

Clinicians from more than 20 leading professional societies are proposing a significant change in the management of osteoarthritis and hoping to improve patient outcomes by approaching it as a chronic condition, subject to screening for risk factors, prevention-oriented interventions, ongoing monitoring, and comprehensive models typical of other chronic diseases. More information and resources are available online.



Education


.
Conference to be held on evidence-based guidelines

The Guidelines International Network North America and the Section on Evidence Based Health Care of the New York Academy of Medicine are sponsoring a conference, "Evidence-Based Guidelines Affecting Policy, Practice and Stakeholders (E-GAPPS)," to be held this December.

The conference will examine how evidence and guidelines shape health care policy and what makes a clinical practice guideline trustworthy. It will also discuss the senders, givers and users of guideline information, as well as adapting, implementing and tracking guideline use. Many plenary speakers will be featured, and moderated breakout sessions will also be held.

The conference will take place Dec. 10-11 at the New York Academy of Medicine in New York City. Registration closes on Nov. 30. More information is available online.



CMS update


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Reminder of ACP webinar on PQRS requirements

ACP is hosting an informational webinar on the PQRS (Physician Quality Reporting System) reporting requirements for physicians on Nov. 29, 2012.

The webinar will focus on the new changes to the PQRS regulations and how physicians can utilize ACP's PQRIwizard tool to comply with reporting regulations. The PQRIwizard tool is ACP's online tool designed to help physicians and other eligible professionals quickly and easily participate in the PQRS requirements. ACP members can purchase the PQRIwizard at a discounted rate.

The webinar will feature a general overview on the PQRIwizard tool, current and future payment risk/rewards for PQRS, eRx and other programs. More information on the webinar is available online.



From ACP Hospitalist


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The next issue of ACP Hospitalist is online

The November issue of ACP Hospitalist is now online. Featured stories include the following:

acpi-20121120-hospcover.jpg

Top Docs. Meet our 2012 Top Hospitalists! Our fifth annual Top Docs issue recognizes 10 dedicated physicians in the field of hospital medicine.

Hold on to your tail. What questions should you ask about malpractice insurance? Limitations in coverage can cause problems if a physician is sued or changes jobs.

Caring for inpatients with chronic diseases from childhood. Hospitalists may need to help smooth the transition from pediatric to adult care.



From the College


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College Master wins 2012 Flexner Award

Ruth-Marie (Rhee) Fincher, MD, MACP, has received the 2012 Abraham Flexner Award for Distinguished Service to Medical Education from the Association of American Medical Colleges.

Dr. Fincher, professor emeritus and former vice dean for academic affairs at the Medical College of Georgia, is the first woman to receive the Flexner Award. As MCG's internal medicine clerkship director, she co-founded Clerkship Directors in Internal Medicine (CDIM) and the Alliance for Clinical Education (ACE). Dr. Fincher served on the executive board of the National Board of Medical Examiners and is a member of the Association of American Medical College's Board of Directors.

Dr. Fincher received her MD degree from Emory University School of Medicine. She was named a College Master in 2008.

More information on Dr. Fincher and the Flexner Award is available online.


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College Fellow awarded Albert Schweitzer Prize for Humanitarianism

James J. O'Connell, MD, FACP, has been awarded the 2012 Albert Schweitzer Prize for Humanitarianism.

Dr. O'Connell, an assistant professor of medicine at Harvard Medical School, received the award for his work with the Boston Health Care for the Homeless Program. The Schweitzer Prize recognizes those whose life and work have significantly improved the health of others in the United States and/or abroad.

More information about the award and Dr. O'Connell's work is available online.



Cartoon caption contest


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Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

acpi-20121120-cartoon.jpg

E‑mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.


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MKSAP Answer and Critique



The correct answer is E: Smoking cessation. This item is available to MKSAP 16 subscribers as item 5 in the Cardiology section.

MKSAP 16 released Part A on July 31. More information is available online.

Smoking cessation may have a greater effect on reducing mortality among patients with coronary artery disease (CAD) than any other intervention or treatment. One half of all smokers will die prematurely from consequences of tobacco abuse, and it is a principal contributor to the development of CAD, sudden cardiac death, acute myocardial infarction (MI), and heart failure.

A meta-analysis of 12 cohort studies of the effect of smoking cessation after myocardial infarction found the combined odds ratio for death in patients who quit was 0.54 compared with patients who continued, equivalent to a number needed to treat of 13. Similar mortality rate benefits have been observed in persons who quit smoking after coronary artery bypass surgery, following coronary angioplasty, and among patients with angiographically documented coronary stenosis. Another cohort study found that mortality among patients who quit smoking after MI approached that of nonsmokers within 3 years.

The benefits of cessation are seen early after cessation and have a significant effect on disease progression, hospital readmission, and mortality. Smokers should be educated to the fact that the relationship between MI and cigarette smoking is dose related and linear.

There is an eight-fold elevation in the odds ratio for persons who smoke more than 40 cigarettes per day.

The benefits of pharmacologic therapy have made it the prime means of successful smoking cessation. There are multiple forms available, including nicotine replacement, bupropion, and varenicline.

Persons with CAD without demonstrable ischemia are recommended by the American College of Cardiology and the American Heart Association (ACC/AHA) to exercise at least 3 times weekly for at least 20 minutes per session. This patient already meets that goal.

Based on recommendations from the ACC/AHA, the target blood pressure for persons with CAD is below 130/80 mm Hg; in those with left ventricular systolic dysfunction, below 120/80 mm Hg. This patient does not have left ventricular systolic dysfunction and his antihypertensive therapy is sufficient.

The National Cholesterol Education Panel (NCEP) Adult Treatment Panel III (ATP III) LDL cholesterol goal for persons at high cardiovascular risk is below 100 mg/dL (2.59 mmol/L). An optional LDL cholesterol goal for persons at very high cardiovascular risk, which includes those with established CAD and continued smoking, is below 70 mg/dL (1.81 mmol/L). This patient's LDL cholesterol level is already below 70 mg/dL (1.81 mmol/L).

Although moderate alcohol consumption (approximately one to three drinks daily) is associated with a lower risk of CAD, excessive alcohol intake accounts for approximately 4% of cases of dilated cardiomyopathy. The level of ingestion has been estimated to be 8 to 21 drinks per day for at least 5 years before abnormalities in cardiac structure and function occur. Reducing this patient's current level of alcohol consumption will not reduce his risk of CAD.

Key Point

  • Mortality among patients who quit smoking following a myocardial infarction approaches that of nonsmokers within 3 years.

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Test yourself

A 66-year-old man is evaluated for vague abdominal pain of several months' duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. Following a physical exam, lab studies, and a CT scan, what is the most appropriate initial management of this patient?

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