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No prehydration prior to contrast-enhanced CT in patients with stage 3 CKD
Background: Postcontrast acute kidney injury (PC-AKI) is known to have a mild, often self-limiting, clinical course. Despite this, preventative measures are advised by international guidelines in high-risk patients.
Study design: The Kompas trial was a multicenter, open-label, noninferiority randomized clinical trial in which 523 patients with stage 3 CKD were randomized to receive no hydration or prehydration with 250 mL of 1.4% sodium bicarbonate in a 1-hour infusion before undergoing elective contrast-enhanced CT. The primary endpoint was the mean relative increase in serum creatinine 2-5 days after contrast administration, compared with baseline.
Setting: Six hospitals in the Netherlands during April 2013–September 2016.
Synopsis: Of the 523 patients, (median age, 74 years), the mean relative increase in creatinine level 2-5 days after contrast administration compared with baseline was 3.0% in the no-prehydration group vs. 3.5% in the prehydration group. This demonstrates that withholding prehydration is noninferior to administrating prehydration. PC-AKI occurred in 7 of 262 patients in the no-prehydration group and 4 of 261 patients in the prehydration group and no patients required dialysis or developed heart failure. These results reassure us that prehydration with sodium bicarbonate can be safely omitted in patients with stage 3 CKD who undergo contrast-enhanced CT.
Bottom line: Prehydration with sodium bicarbonate is not needed to prevent additional renal injury in patients with CKD stage 3 undergoing contrast-enhanced CT imaging.
Citation: Timal RJ et al. Effect of no prehydration vs sodium bicarbonate prehydration prior to contrast-enhanced computed tomography in the prevention of postcontrast acute kidney injury in adults with chronic kidney disease: The Kompas Randomized Clinical Trial. JAMA Intern Med. 2020 Feb 17. doi: 10.1001/jamainternmed.2019.7428.
Dr. Moulder is assistant professor of medicine, section of hospital medicine, at the University of Virginia School of Medicine, Charlottesville.
Background: Postcontrast acute kidney injury (PC-AKI) is known to have a mild, often self-limiting, clinical course. Despite this, preventative measures are advised by international guidelines in high-risk patients.
Study design: The Kompas trial was a multicenter, open-label, noninferiority randomized clinical trial in which 523 patients with stage 3 CKD were randomized to receive no hydration or prehydration with 250 mL of 1.4% sodium bicarbonate in a 1-hour infusion before undergoing elective contrast-enhanced CT. The primary endpoint was the mean relative increase in serum creatinine 2-5 days after contrast administration, compared with baseline.
Setting: Six hospitals in the Netherlands during April 2013–September 2016.
Synopsis: Of the 523 patients, (median age, 74 years), the mean relative increase in creatinine level 2-5 days after contrast administration compared with baseline was 3.0% in the no-prehydration group vs. 3.5% in the prehydration group. This demonstrates that withholding prehydration is noninferior to administrating prehydration. PC-AKI occurred in 7 of 262 patients in the no-prehydration group and 4 of 261 patients in the prehydration group and no patients required dialysis or developed heart failure. These results reassure us that prehydration with sodium bicarbonate can be safely omitted in patients with stage 3 CKD who undergo contrast-enhanced CT.
Bottom line: Prehydration with sodium bicarbonate is not needed to prevent additional renal injury in patients with CKD stage 3 undergoing contrast-enhanced CT imaging.
Citation: Timal RJ et al. Effect of no prehydration vs sodium bicarbonate prehydration prior to contrast-enhanced computed tomography in the prevention of postcontrast acute kidney injury in adults with chronic kidney disease: The Kompas Randomized Clinical Trial. JAMA Intern Med. 2020 Feb 17. doi: 10.1001/jamainternmed.2019.7428.
Dr. Moulder is assistant professor of medicine, section of hospital medicine, at the University of Virginia School of Medicine, Charlottesville.
Background: Postcontrast acute kidney injury (PC-AKI) is known to have a mild, often self-limiting, clinical course. Despite this, preventative measures are advised by international guidelines in high-risk patients.
Study design: The Kompas trial was a multicenter, open-label, noninferiority randomized clinical trial in which 523 patients with stage 3 CKD were randomized to receive no hydration or prehydration with 250 mL of 1.4% sodium bicarbonate in a 1-hour infusion before undergoing elective contrast-enhanced CT. The primary endpoint was the mean relative increase in serum creatinine 2-5 days after contrast administration, compared with baseline.
Setting: Six hospitals in the Netherlands during April 2013–September 2016.
Synopsis: Of the 523 patients, (median age, 74 years), the mean relative increase in creatinine level 2-5 days after contrast administration compared with baseline was 3.0% in the no-prehydration group vs. 3.5% in the prehydration group. This demonstrates that withholding prehydration is noninferior to administrating prehydration. PC-AKI occurred in 7 of 262 patients in the no-prehydration group and 4 of 261 patients in the prehydration group and no patients required dialysis or developed heart failure. These results reassure us that prehydration with sodium bicarbonate can be safely omitted in patients with stage 3 CKD who undergo contrast-enhanced CT.
Bottom line: Prehydration with sodium bicarbonate is not needed to prevent additional renal injury in patients with CKD stage 3 undergoing contrast-enhanced CT imaging.
Citation: Timal RJ et al. Effect of no prehydration vs sodium bicarbonate prehydration prior to contrast-enhanced computed tomography in the prevention of postcontrast acute kidney injury in adults with chronic kidney disease: The Kompas Randomized Clinical Trial. JAMA Intern Med. 2020 Feb 17. doi: 10.1001/jamainternmed.2019.7428.
Dr. Moulder is assistant professor of medicine, section of hospital medicine, at the University of Virginia School of Medicine, Charlottesville.
Noninvasive cardiac testing to rule out acute coronary syndromes provides no benefit in low-risk chest pain patients
Background: The 2014 American College of Cardiology/American Heart Association clinical guideline includes a recommendation for noninvasive testing (exercise test or coronary commuted tomographic angiography [CCTA]) in patients with chest pain but no evidence of ischemia. The ROMICAT-II (Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography) trial randomized 1,000 ED patients with chest pain to undergo CCTA or usual care with unknown benefits and risks of this testing recommendation. The question of whether this testing may be omitted is addressed in secondary analysis.
Study design: Retrospective analysis of the ROMICAT-II trial data.
Setting: Emergency department.
Synopsis: As compared with 882 patients who underwent noninvasive testing, 118 patients in the ROMICAT-II usual care group who did not undergo noninvasive testing had shorter lengths of stay (20.3 vs. 27.9 hours; P less than .001), lower rates of diagnostic testing (P less than .001), angiography (2% vs. 11%; P less than .001), and lower costs ($2,261.50 vs. $2,584.30). There was no difference in percutaneous coronary intervention (2% vs. 5%; P = .15), coronary artery bypass surgery (0% vs. 1%; P = .61), major adverse cardiac events (MACE; 2% vs. 1%; P = .24), or return ED visits (5.8% vs. 2.8%; P = .08) during the 28-day follow-up period. These findings suggest noninvasive cardiac testing may be omitted in low- to intermediate-risk patients presenting with chest pain. However, this study was not designed or powered to address this question and patients were not randomized. These data may support hospitalists who choose not to order noninvasive testing in ED patients with chest pain.
Bottom line: In this secondary analysis of ROMICAT-II clinical trial data, patients who underwent clinical evaluation without noninvasive testing had shorter length of stay, less diagnostic testing, lower radiation exposure, and reduced costs with no difference in missed diagnosis of acute coronary syndromes, development of MACE, or return ED visits.
Citation: Reinhardt SW et al. Noninvasive cardiac testing vs. clinical evaluation alone in acute chest pain: A secondary analysis of the ROMICAT-II randomized clinical trial. JAMA Intern Med. 2018 Feb 1;178(2):212-9.
Dr. Moulder is assistant professor, University of Virginia Health System.
Background: The 2014 American College of Cardiology/American Heart Association clinical guideline includes a recommendation for noninvasive testing (exercise test or coronary commuted tomographic angiography [CCTA]) in patients with chest pain but no evidence of ischemia. The ROMICAT-II (Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography) trial randomized 1,000 ED patients with chest pain to undergo CCTA or usual care with unknown benefits and risks of this testing recommendation. The question of whether this testing may be omitted is addressed in secondary analysis.
Study design: Retrospective analysis of the ROMICAT-II trial data.
Setting: Emergency department.
Synopsis: As compared with 882 patients who underwent noninvasive testing, 118 patients in the ROMICAT-II usual care group who did not undergo noninvasive testing had shorter lengths of stay (20.3 vs. 27.9 hours; P less than .001), lower rates of diagnostic testing (P less than .001), angiography (2% vs. 11%; P less than .001), and lower costs ($2,261.50 vs. $2,584.30). There was no difference in percutaneous coronary intervention (2% vs. 5%; P = .15), coronary artery bypass surgery (0% vs. 1%; P = .61), major adverse cardiac events (MACE; 2% vs. 1%; P = .24), or return ED visits (5.8% vs. 2.8%; P = .08) during the 28-day follow-up period. These findings suggest noninvasive cardiac testing may be omitted in low- to intermediate-risk patients presenting with chest pain. However, this study was not designed or powered to address this question and patients were not randomized. These data may support hospitalists who choose not to order noninvasive testing in ED patients with chest pain.
Bottom line: In this secondary analysis of ROMICAT-II clinical trial data, patients who underwent clinical evaluation without noninvasive testing had shorter length of stay, less diagnostic testing, lower radiation exposure, and reduced costs with no difference in missed diagnosis of acute coronary syndromes, development of MACE, or return ED visits.
Citation: Reinhardt SW et al. Noninvasive cardiac testing vs. clinical evaluation alone in acute chest pain: A secondary analysis of the ROMICAT-II randomized clinical trial. JAMA Intern Med. 2018 Feb 1;178(2):212-9.
Dr. Moulder is assistant professor, University of Virginia Health System.
Background: The 2014 American College of Cardiology/American Heart Association clinical guideline includes a recommendation for noninvasive testing (exercise test or coronary commuted tomographic angiography [CCTA]) in patients with chest pain but no evidence of ischemia. The ROMICAT-II (Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography) trial randomized 1,000 ED patients with chest pain to undergo CCTA or usual care with unknown benefits and risks of this testing recommendation. The question of whether this testing may be omitted is addressed in secondary analysis.
Study design: Retrospective analysis of the ROMICAT-II trial data.
Setting: Emergency department.
Synopsis: As compared with 882 patients who underwent noninvasive testing, 118 patients in the ROMICAT-II usual care group who did not undergo noninvasive testing had shorter lengths of stay (20.3 vs. 27.9 hours; P less than .001), lower rates of diagnostic testing (P less than .001), angiography (2% vs. 11%; P less than .001), and lower costs ($2,261.50 vs. $2,584.30). There was no difference in percutaneous coronary intervention (2% vs. 5%; P = .15), coronary artery bypass surgery (0% vs. 1%; P = .61), major adverse cardiac events (MACE; 2% vs. 1%; P = .24), or return ED visits (5.8% vs. 2.8%; P = .08) during the 28-day follow-up period. These findings suggest noninvasive cardiac testing may be omitted in low- to intermediate-risk patients presenting with chest pain. However, this study was not designed or powered to address this question and patients were not randomized. These data may support hospitalists who choose not to order noninvasive testing in ED patients with chest pain.
Bottom line: In this secondary analysis of ROMICAT-II clinical trial data, patients who underwent clinical evaluation without noninvasive testing had shorter length of stay, less diagnostic testing, lower radiation exposure, and reduced costs with no difference in missed diagnosis of acute coronary syndromes, development of MACE, or return ED visits.
Citation: Reinhardt SW et al. Noninvasive cardiac testing vs. clinical evaluation alone in acute chest pain: A secondary analysis of the ROMICAT-II randomized clinical trial. JAMA Intern Med. 2018 Feb 1;178(2):212-9.
Dr. Moulder is assistant professor, University of Virginia Health System.