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Abnormal exercise EKG in the setting of normal stress echo linked with increased CV risk
Background: Exercise EKG is often integrated with stress echocardiography, but discordance with +EKG/–Echo has unknown significance.
Study design: Observational cohort study.
Setting: Duke University Medical Center, Durham, N.C.
Synopsis: 47,944 patients without known coronary artery disease underwent exercise stress echocardiogram (Echo) with stress EKG. Of those patients, 8.5% had +EKG/–Echo results, which was associated with annualized event rate of adverse cardiac events of 1.72%, which is higher than the 0.89% of patients with –EKG/–Echo results. This was most significant for composite major adverse cardiovascular events less than 30 days out, with an adjusted hazard ratio of 8.06 (95% confidence interval, 5.02-12.94). For major adverse cardiovascular events greater than 30 days out, HR was 1.25 (95% CI 1.02-1.53).
Bottom line: Patients with +EKG/–Echo findings appear to be at higher risk of adverse cardiac events, especially in the short term.
Citation: Daubert MA et al. Implications of abnormal exercise electrocardiography with normal stress echocardiography. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6958.
Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
Background: Exercise EKG is often integrated with stress echocardiography, but discordance with +EKG/–Echo has unknown significance.
Study design: Observational cohort study.
Setting: Duke University Medical Center, Durham, N.C.
Synopsis: 47,944 patients without known coronary artery disease underwent exercise stress echocardiogram (Echo) with stress EKG. Of those patients, 8.5% had +EKG/–Echo results, which was associated with annualized event rate of adverse cardiac events of 1.72%, which is higher than the 0.89% of patients with –EKG/–Echo results. This was most significant for composite major adverse cardiovascular events less than 30 days out, with an adjusted hazard ratio of 8.06 (95% confidence interval, 5.02-12.94). For major adverse cardiovascular events greater than 30 days out, HR was 1.25 (95% CI 1.02-1.53).
Bottom line: Patients with +EKG/–Echo findings appear to be at higher risk of adverse cardiac events, especially in the short term.
Citation: Daubert MA et al. Implications of abnormal exercise electrocardiography with normal stress echocardiography. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6958.
Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
Background: Exercise EKG is often integrated with stress echocardiography, but discordance with +EKG/–Echo has unknown significance.
Study design: Observational cohort study.
Setting: Duke University Medical Center, Durham, N.C.
Synopsis: 47,944 patients without known coronary artery disease underwent exercise stress echocardiogram (Echo) with stress EKG. Of those patients, 8.5% had +EKG/–Echo results, which was associated with annualized event rate of adverse cardiac events of 1.72%, which is higher than the 0.89% of patients with –EKG/–Echo results. This was most significant for composite major adverse cardiovascular events less than 30 days out, with an adjusted hazard ratio of 8.06 (95% confidence interval, 5.02-12.94). For major adverse cardiovascular events greater than 30 days out, HR was 1.25 (95% CI 1.02-1.53).
Bottom line: Patients with +EKG/–Echo findings appear to be at higher risk of adverse cardiac events, especially in the short term.
Citation: Daubert MA et al. Implications of abnormal exercise electrocardiography with normal stress echocardiography. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6958.
Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
Post–acute kidney injury proteinuria predicts subsequent kidney disease progression
Background: Recent studies have shown that the level of proteinuria increases after AKI. It is not yet shown if this increases risk of kidney disease progression.
Study design: Prospective matched cohort study.
Setting: North American hospitals.
Synopsis: A total of 769 hospitalized adults with AKI were matched with those without based on clinical center and preadmission chronic kidney disease (CKD) status. Study authors found that albumin/creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR) 3 months after hospitalization were highly associated with kidney disease progression, with a hazard ratio of 1.53 for each doubling (95% confidence interval, 1.43-1.64).
Episodes of AKI were also associated with progression, but this is severely attenuated once adjusted for ACR, eGFR, and traditional CKD risk factors. This suggests more routine quantification of proteinuria after AKI for better risk stratification.
Bottom line: Posthospitalization ACR predicts progression of kidney disease.
Citation: Hsu CY et al. Post–acute kidney injury proteinuria and subsequent kidney disease progression. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6390.
Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
Background: Recent studies have shown that the level of proteinuria increases after AKI. It is not yet shown if this increases risk of kidney disease progression.
Study design: Prospective matched cohort study.
Setting: North American hospitals.
Synopsis: A total of 769 hospitalized adults with AKI were matched with those without based on clinical center and preadmission chronic kidney disease (CKD) status. Study authors found that albumin/creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR) 3 months after hospitalization were highly associated with kidney disease progression, with a hazard ratio of 1.53 for each doubling (95% confidence interval, 1.43-1.64).
Episodes of AKI were also associated with progression, but this is severely attenuated once adjusted for ACR, eGFR, and traditional CKD risk factors. This suggests more routine quantification of proteinuria after AKI for better risk stratification.
Bottom line: Posthospitalization ACR predicts progression of kidney disease.
Citation: Hsu CY et al. Post–acute kidney injury proteinuria and subsequent kidney disease progression. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6390.
Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
Background: Recent studies have shown that the level of proteinuria increases after AKI. It is not yet shown if this increases risk of kidney disease progression.
Study design: Prospective matched cohort study.
Setting: North American hospitals.
Synopsis: A total of 769 hospitalized adults with AKI were matched with those without based on clinical center and preadmission chronic kidney disease (CKD) status. Study authors found that albumin/creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR) 3 months after hospitalization were highly associated with kidney disease progression, with a hazard ratio of 1.53 for each doubling (95% confidence interval, 1.43-1.64).
Episodes of AKI were also associated with progression, but this is severely attenuated once adjusted for ACR, eGFR, and traditional CKD risk factors. This suggests more routine quantification of proteinuria after AKI for better risk stratification.
Bottom line: Posthospitalization ACR predicts progression of kidney disease.
Citation: Hsu CY et al. Post–acute kidney injury proteinuria and subsequent kidney disease progression. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6390.
Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
Epidemiology and costs of sepsis in the United States
Background: Sepsis is responsible for an increasingly disproportionate fraction of health care burden. Delays in diagnosis of sepsis are associated with worse outcomes.
Study design: Retrospective observational study.
Setting: Premier Healthcare database, including 20% of U.S. private/academic hospitals.
Synopsis: With use of the Premier Healthcare database, researchers identified 2,566,689 cases of sepsis using ICD-9 and MS-DRG codes between Jan. 1, 2010, and Sept. 30, 2016. Increasing severity of sepsis was associated with increasing mortality and cost, but there was a large discrepancy in cost in patients with sepsis present at admission versus those without it at admission ($18,023 vs. $51,022) and was associated with increases in both mean hospital length of stay and mortality rate across all levels of sepsis severity.
Bottom line: Early identification of sepsis (at admission vs. later in the stay) may be important as a factor to reduce its overall burden on the health care system.
Citation: Paoli CJ et al. Epidemiology and costs of sepsis in the United States – An analysis based on timing of diagnosis and severity level. Crit Care Med. 2018 Dec;46(12):1889-97.
Dr. Ho is an assistant professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.
Background: Sepsis is responsible for an increasingly disproportionate fraction of health care burden. Delays in diagnosis of sepsis are associated with worse outcomes.
Study design: Retrospective observational study.
Setting: Premier Healthcare database, including 20% of U.S. private/academic hospitals.
Synopsis: With use of the Premier Healthcare database, researchers identified 2,566,689 cases of sepsis using ICD-9 and MS-DRG codes between Jan. 1, 2010, and Sept. 30, 2016. Increasing severity of sepsis was associated with increasing mortality and cost, but there was a large discrepancy in cost in patients with sepsis present at admission versus those without it at admission ($18,023 vs. $51,022) and was associated with increases in both mean hospital length of stay and mortality rate across all levels of sepsis severity.
Bottom line: Early identification of sepsis (at admission vs. later in the stay) may be important as a factor to reduce its overall burden on the health care system.
Citation: Paoli CJ et al. Epidemiology and costs of sepsis in the United States – An analysis based on timing of diagnosis and severity level. Crit Care Med. 2018 Dec;46(12):1889-97.
Dr. Ho is an assistant professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.
Background: Sepsis is responsible for an increasingly disproportionate fraction of health care burden. Delays in diagnosis of sepsis are associated with worse outcomes.
Study design: Retrospective observational study.
Setting: Premier Healthcare database, including 20% of U.S. private/academic hospitals.
Synopsis: With use of the Premier Healthcare database, researchers identified 2,566,689 cases of sepsis using ICD-9 and MS-DRG codes between Jan. 1, 2010, and Sept. 30, 2016. Increasing severity of sepsis was associated with increasing mortality and cost, but there was a large discrepancy in cost in patients with sepsis present at admission versus those without it at admission ($18,023 vs. $51,022) and was associated with increases in both mean hospital length of stay and mortality rate across all levels of sepsis severity.
Bottom line: Early identification of sepsis (at admission vs. later in the stay) may be important as a factor to reduce its overall burden on the health care system.
Citation: Paoli CJ et al. Epidemiology and costs of sepsis in the United States – An analysis based on timing of diagnosis and severity level. Crit Care Med. 2018 Dec;46(12):1889-97.
Dr. Ho is an assistant professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.
Oral anticoagulant and PPI cotherapy cuts upper GI bleed risk
Background: PPIs reduce gastric acid production, promote ulcer healing, and prevent ulcer recurrence; however, limited evidence is available describing the incidence of anticoagulant-related serious upper GI tract bleeding from the newer non–vitamin K anticoagulants and PPI cotherapy.
Study design: Retrospective cohort.
Setting: Medicare enrollees.
Synopsis: With use of computerized Medicare beneficiaries files, researchers identified 1,643,123 patients with 1,713,183 new episodes of oral anticoagulant treatment between Jan. 1, 2011, and Sept. 30, 2015. This analysis showed that cotherapy with PPIs was associated with a lower incidence of upper GI bleed, with the largest difference associated with dabigatran with an incidence rate ratio of 0.49 (95% CI, 0.52-0.85), followed by warfarin (IRR, 0.65; 95%CI, 0.62-0.69), apixaban (IRR, 0.66; 95% CI, 0.52-0.85), and rivaroxaban (IRR, 0.75; 95% CI, 0.68-0.84).
Generalizability was limited by population (Medicare enrollees) and the study excluded prior hospitalizations for GI bleed, as well as switches in anticoagulant therapy during the study period.
Bottom line: PPI cotherapy with oral anticoagulation reduces risk of hospitalization for upper GI bleed.
Citation: Ray WA et al. Association of oral anticoagulants and proton pump inhibitor cotherapy with hospitalization for upper gastrointestinal tract bleeding. JAMA. 2018 Dec 4;320(21):2221-30.
Dr. Ho is an assistant professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.
Background: PPIs reduce gastric acid production, promote ulcer healing, and prevent ulcer recurrence; however, limited evidence is available describing the incidence of anticoagulant-related serious upper GI tract bleeding from the newer non–vitamin K anticoagulants and PPI cotherapy.
Study design: Retrospective cohort.
Setting: Medicare enrollees.
Synopsis: With use of computerized Medicare beneficiaries files, researchers identified 1,643,123 patients with 1,713,183 new episodes of oral anticoagulant treatment between Jan. 1, 2011, and Sept. 30, 2015. This analysis showed that cotherapy with PPIs was associated with a lower incidence of upper GI bleed, with the largest difference associated with dabigatran with an incidence rate ratio of 0.49 (95% CI, 0.52-0.85), followed by warfarin (IRR, 0.65; 95%CI, 0.62-0.69), apixaban (IRR, 0.66; 95% CI, 0.52-0.85), and rivaroxaban (IRR, 0.75; 95% CI, 0.68-0.84).
Generalizability was limited by population (Medicare enrollees) and the study excluded prior hospitalizations for GI bleed, as well as switches in anticoagulant therapy during the study period.
Bottom line: PPI cotherapy with oral anticoagulation reduces risk of hospitalization for upper GI bleed.
Citation: Ray WA et al. Association of oral anticoagulants and proton pump inhibitor cotherapy with hospitalization for upper gastrointestinal tract bleeding. JAMA. 2018 Dec 4;320(21):2221-30.
Dr. Ho is an assistant professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.
Background: PPIs reduce gastric acid production, promote ulcer healing, and prevent ulcer recurrence; however, limited evidence is available describing the incidence of anticoagulant-related serious upper GI tract bleeding from the newer non–vitamin K anticoagulants and PPI cotherapy.
Study design: Retrospective cohort.
Setting: Medicare enrollees.
Synopsis: With use of computerized Medicare beneficiaries files, researchers identified 1,643,123 patients with 1,713,183 new episodes of oral anticoagulant treatment between Jan. 1, 2011, and Sept. 30, 2015. This analysis showed that cotherapy with PPIs was associated with a lower incidence of upper GI bleed, with the largest difference associated with dabigatran with an incidence rate ratio of 0.49 (95% CI, 0.52-0.85), followed by warfarin (IRR, 0.65; 95%CI, 0.62-0.69), apixaban (IRR, 0.66; 95% CI, 0.52-0.85), and rivaroxaban (IRR, 0.75; 95% CI, 0.68-0.84).
Generalizability was limited by population (Medicare enrollees) and the study excluded prior hospitalizations for GI bleed, as well as switches in anticoagulant therapy during the study period.
Bottom line: PPI cotherapy with oral anticoagulation reduces risk of hospitalization for upper GI bleed.
Citation: Ray WA et al. Association of oral anticoagulants and proton pump inhibitor cotherapy with hospitalization for upper gastrointestinal tract bleeding. JAMA. 2018 Dec 4;320(21):2221-30.
Dr. Ho is an assistant professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.