Hospital Medicine Literature Review II

Amarprit Bains

Portland VA Medical Center

Oregon Health and Science University

September 25, 2020

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Disclosures

• None

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General Principles

• Practice changing or confirming for our day-to-day workflow

• Trying to avoid esotericaOHSU

Y92.253Injured at an opera houseOHSU

Objective

• Screen for VTE in a cost-efficient manner

• Treat malignancy-associated VTE in a cost-efficient mannerOHSU

Case #1

• Ms. A is a 62 yo woman with PMH of asthma who presents to the ER with chest pain

• Vitals: T 99.3, BP 153/91, HR 108, R 20, O2 sat 96% on RA

• Exam: unremarkable

• EKG: sinus tachycardia without acute ST or T-wave changes

• CXR: no focal infiltrate

• Labs: Trop <0.01, D-dimer 0.91mcg/mL (910ng/mL)

• The ER calls you to admit this patient. What is your next step?

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Case #1: what is your next step?

a) Admit the patient for cardiac rule-out

b) Check a procalcitonin to look for a pulmonary infection

c) Request a CTA Thorax to look for PE

d) Order BLE dopplers to look for DVTOHSU

Case #1 - Clinical Tools

• Pulmonary Embolism Rule-Out Criteria

• Wells Score

• D-dimer• Existing data supports using D-dimer as a screening tool in patients with low

to moderate pre-test probability for VTE

• Typical cut-off is 0.5mcg/mL (500ng/mL)OHSU

Case #1: Clinical Tools

• Pulmonary Embolism Rule-Out Criteria (PERC) score is 2 (age>50, HR>100)• PE cannot be ruled out if any criteria are positive

• Wells Score is 1.5 (HR >100)

• D-dimer is >0.5mcg/mLOHSU

Case #1: Diagnosis of PE with D-dimer Adjusted to Clinical Probability• Published 11/28/19 in NEJM

• Further stratified the exclusion range based on clinical pre-test probability (C-PTP)

• Prospective, non-RCT (i.e. no control group)

• Primary outcome: symptomatic, objectively verified VTE at 90 days

• Patient population:• 2017 patients; most were in the ER and only one was inpatient

• Excluded pregnant patients or anyone who had gotten major surgery in the past 21 days

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Case #1: Pulmonary Embolism Guided D-dimer Protocol• Clinical pre-test probability (C-PTP) determined using the Wells

Criteria• Low C-PTP: Wells 0-4

• Moderate C-PTP: Wells 4.5-6

• High C-PTP: Wells >6.5OHSU

Case #1: Pulmonary Embolism Guided D-dimer Protocol• Patients with a low or moderate pre-test probability got a d-dimer

• Low C-PTP (Wells 0-4): d-dimer <1mcg/mL (1000ng/mL) got no further w/u or treatment for VTE

• Moderate C-PTP (Wells 4.5-6): d-dimer <0.5mcg/mL (500ng/mL) got no further w/u or treatment for VTE

• High C-PTP (Wells >6.5): all got chest imaging

• Follow-up for all patients done either in clinic or by phone at 90 days and patients with symptoms concerning for DVT or PE got imagingOHSU

Case #1: Pulmonary Embolism Guided D-dimer Protocol• 1970 (97%) of the patients had low or moderate C-PTP

• 1325 (67.3%) had a negative d-dimer and did not receive anticoagulation

• None of these patients had VTE on f/u

• Of the 1285 patients with a low C-PTP who had a d-dimer between 0.5-0.999mcg/mL (500-999ng/mL), none had VTE during f/u

• Chest imaging reduced by ~17% (65.7-> 48.1%) using the protocolOHSU

Case #1: Pulmonary Embolism Guided D-dimer Protocol• Criticisms/Things of note:

• Bulk of the patients were in the low C-PTP group and this is where the benefit was

• Moderate risk patients were a small percentage of the total (only 218 of 2017)• Results were statistically significant howeverOHSU

Case #1: Take-Away Points

• A higher D-dimer threshold of <1mcg/mL (1000ng/mL) can be used to exclude VTE in patients with low C-PTP (Wells score 0-4)

• A D-dimer threshold of <0.5mcg/mL (500ng/mL) can be used to exclude VTE in patients with moderate C-PTP (Well score 4.5-6)OHSU

Case #1: what is your next step?

a) Admit the patient for cardiac rule-out

b) Check a procalcitonin to look for a pulmonary infection

c) Request a CTA Thorax to look for PE

d) Order BLE dopplers to look for DVTOHSU

Case #2

• Ms. B is the identical twin of Ms. A

• 62 yo woman with PMH of tobacco use disorder with recently diagnosed lung cancer (undergoing chemotherapy) who presents to the ER with chest pain

• Vitals: T 99.3, BP 153/91, HR 108, R 20, O2 sat 96% on RA

• Exam: unilateral RLE edema

• EKG: sinus tachycardia without acute ST or T-wave changes

• CXR: no focal infiltrate

• Labs: Trop <0.01, D-dimer 0.91mcg/mL (910ng/mL)

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Case #2 – Clinical tools

• Pulmonary Embolism Rule-Out Criteria (PERC) score is 3 (age>50, HR>100, unilateral leg swelling)• PE cannot be ruled out

• Wells Score is 5.5 (clinical signs of a DVT, HR >100, malignancy)

• D-dimer is >0.5mcg/mLOHSU

Case #2 – Clinical tools

• Moderate C-PTP of 5.5; D-dimer >0.5mcg/mL

• Gets a CTA Thorax which is positive for a large saddle embolus

• TTE without heart strain

• She is started on a heparin infusion and is admitted for monitoring

• She remains stable and on HD#3 is ready for dischargeOHSU

Case #2 – what medication at discharge?

a) Warfarin

b) Enoxaparin

c) Dabigatran

d) RivaroxabanOHSU

Case #2 – What we know

• Standard practice is to treat patients who have a malignancy associated DVT or PE with low molecular weight heparinOHSU

Case #2 – Newer data

• 2018 NEJM – Edoxaban for the Treatment of Cancer-Associated Venous Thrombembolism [Raskob, et al]• Oral Edoxaban was non-inferior to dalteparin for a composite outcome of

recurrent VTE or major bleeding

• 2018 Journal of Clinical Oncology – Comparison of an Oral Factor XaInhibitor with LWMH in patients with Cancer with VTE [Young, et al]• Rivaroxaban was associated with low VTE recurrence but higher clinically

relevant non-major bleedingOHSU

Case #2 – Even Newer Data

• Two studies have been published in 2020

• ADAM-VTE [Journal of Thrombosis & Hemostasis] - Apixaban and Dalteparin in Active Malignancy-associated VTE• Apixaban was associated with lower VTE recurrence and lower major bleeding

than Dalteparin

• CARAVAGGIO [NEJM] – Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer• Apixaban was non-inferior to Dalteparin for malignancy associated VTE

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Case #2 – Systematic Review

• A recent systematic review [Thrombosis & Hemostasis]: • Included the four trials previously mentioned

• Factor Xa inhibitors (Apixaban, Rivaroxaban, Edoxaban) but NOT Dabigatran significantly decreased the risk of recurrent VTE compared to Dalteparin• Dabigatran was not included in the studies

• There was a non-statistically significant increase in major bleeding

• GI and genitourinary sites are the most common locations of major bleeding with Factor Xa inhibitorsOHSU

Case #2: Take-Away Points

• Oral factor Xa inhibitors (Edoxaban, Rivaroxaban, Apixaban) are safe alternatives for treatment of VTE in patients who have cancer• Improved compliance with treatment may have driven better outcomes

• Use caution in patients with GI malignancies at high risk of bleeding

• Comparisons were done against Dalteparin so it’s possible this may not apply to Enoxparin though that seems unlikely OHSU

Case #2 – what medication at discharge?

a) Warfarin

b) Enoxaparin

c) Dabigatran

d) RivaroxabanOHSU

Quick Hits – TAVR vs SAVR

• PARTNER clinical trials looked at TAVR vs SAVR in symptomatic, severe AS

• PARTNER A – TAVR in patients too high risk for SAVR

• PARTNER B – TAVR in patients with high risk for surgery vs SAVR

• PARTNER 2 – TAVR in patients with intermediate risk for surgery vs SAVR

• PARTNER 3 – TAVR in patients with low risk of surgery• Found TAVR was non-inferior to SAVR• Data strongly suggested TAVR was better (1.5% absolute reduction in

mortality)

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Quick Hits – TAVR vs SAVR

• TAVR is non-inferior or superior than SAVR for all risk-level patients• Excluding bicuspid aortic valves or mixed AS/AI

• Long-term durability of TAVR is still being evaluated so, as of yet, it is not the definitive treatment for symptomatic aortic stenosisOHSU

V00.01XDPedestrian on foot injured in collision with roller-skater, subsequent encounterOHSU

Objective

• Manage UGIB using the latest data

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Case #3

• Three months after discharge, Ms. B is readmitted with hypotension, tachycardia and melena concerning for an UGIB

• An unusually nerdy trauma surgeon is nearby when you get the ER call and tells you about how Tranexamic acid (TXA) is helpful in trauma patients to prevents bleeding• Cites a Cochrane systematic review and meta-analysis that showed a

reduction in all cause mortality for patients with an UGIB treated with TXA

• Suggests you add TXA to the patient's admission bundle

• In addition to usual care, should Tranexamic acid be used in this patient?

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Case #3 - Tranexamic acid

• Clots are formed from the conversion of fibrinogen to fibrin• Plasmin breaks down fibrin clots

• Tranexamic acid works by inhibiting the creation of plasmin• This reduces clot breakdown

• In theory, this would keep clots stable and reduce bleedingOHSU

Case #3: What we know

• TXA has been shown to reduce surgical bleeding and prevent death in traumatic and post-partum hemorrhage

• Problem with the systematic review of TXA in UGI bleeding: • Included small studies that had underlying bias issues

• Was intended to be hypothesis generating not practice changingOHSU

Case #3: HALT-IT

• HALT-IT included 12,009 patients from 164 hospitals in 15 countries

• Population: adults with UGI bleeding

• Primary outcome:• Death due to bleeding within five days of randomization

• Five days chosen because of the short half-life of TXA; not thought to affect rebleeding

• Secondary outcomes:• Death due to bleeding within 24 hours, death within 28 days of

randomization, all-cause mortality at 28 days among others

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Case #3: HALT-IT Results

• Primary outcome: • TXA did not reduce death from UGI bleeding within five days

• Secondary outcomes:• No statistically significant difference in death at 24 hours or 28 days

• Re-bleeding events similar in both groups

• There was a non-statistically significant increased risk of VTE in the TXA group

• No change in outcome when geographic location of the hospital, prior anticoagulant use and systolic blood pressure were accounted for

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Case #3: Take-Away Points

• There is no role for Tranexamic acid in patients with an UGIB

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V80.721AOccupant of animal-drawn vehicle injured in collision with other animal-drawn vehicle, initial encounter

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Objective

• Optimally manage antibiotic duration in Gram negative rod sepsis

• Optimal manage resuscitation in GNR septic shockOHSU

Case #4

• Ms. C is a 62 yo woman with a PMH significant only for R knee TKA six months prior who presents to the ER with three days of fevers, chills and dysuria

• Vitals: T 101.3, BP 90/57, HR 115, R 20, O2 sat 96% on RA

• Exam: tachycardic, regular, suprapubic TTP on exam. No CVAT

• Labs:• CBC: WBC 21

• Chem-7: Cr 1

• U/A with many WBC, no RBCs or blood, large LE and positive nitrites

• Other: Procalcitonin of 2.5, CRP of 100

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Case #4

• Imaging:• CT A/P with contrast shows bladder inflammation c/w cystitis without

evidence of pyelonephritis, peri-nephric abscess or stones

• Given 2L LR with improvement in BP to 110/87 and HR to 98

• Started on Pip/Tazo and admittedOHSU

Case #4

• HD#1-5• Fever, tachycardia and hypotension gradually improve over days 1-3 and vitals

return to her baseline range by early on HD#4

• Blood cultures from the ER grow pan-sensitive E. Coli in both bottles with final sensitivities back on HD#5

• Urine culture speciates out pan-sensitive E. Coli; speciation occurs on HD#5

• By HD#5, WBC 7, Procalcitonin 0.04 and CRP 20OHSU

Case #4 – How Long Should She Be Treated?

a) Stop antibiotics now (5-day total course)

b) 7-day total course

c) 10-day total course

d) 14-day total courseOHSU

Case #4 – What we know

• A non-inferiority RCT from 2019 published by Yahav, et al in Clinical Infectious Disease compared seven vs 14 days of antibiotic therapy for GNR bacteremia• Patients had to be afebrile and hemodynamically stable for at least 48 hours

• Majority of infections were urinary (68%) and intra-abdominal (12%)

• No significant difference seen on the composite endpoint of all-cause mortality, clinical failure, suppurative or distance complications or readmission within 90 days

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Case #4 – Newer Data

• Von Dach, et all published a study in 06/2020 in JAMA taking it one step further• Non-inferiority RCT comparing CRP-guided antibiotic treatment duration and

a 7-day treatment duration versus a 14-day treatment duration for uncomplicated gram-negative rod bacteremia

• Patients had to have GNR in at least one blood cultures and not have been febrile or hemodynamically unstable in the past 24 hours

• Day 1 was considered the first day of efficacious antibiotic treatment and patients were randomized on day 5

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Case #4 – CRP Protocol

• Checked on arrival and daily per local practice

• Antibiotics stopped when the CRP had declined by 75% of peak and patients were afebrile for 48 hours• E.g. if peak CRP was 100, antibiotics stopped when CRP was 25 or less

• If the CRP was still above the threshold at 14-days, it was no longer checkedOHSU

Case #4 – Infection Characteristics

• Like the Yahav study, majority of infections were urinary (71%) and intra-abdominal (12%)

• E. Coli was the most common pathogen (74%) followed by Klebsiella (17%)• This was also similar to the Yahav studyOHSU

Case #4 – Primary Outcome

• Defined as clinical failure at day 30 which could be any of the following:• Recurrent bacteremia

• Restarting antibiotics

• Local (suppurative) or distant spread of infection

• Death

• Results:• No difference in outcomes seen between the CRP group or the 7-day fixed

group compared to the 14-day group

• Similar findings at the 60- and 90-day marks

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Case #4 – Secondary Outcomes

• Treatment Length:• Mean treatment lengths were the same in the CRP and 7-day fixed group

• Of note, the mean length was 9 days in both as antibiotic duration was at the discretion of the treating provider. Mean treatment length was 16 days in the 14-day fixed group

• C. Diff:• Occurred more in the CRP-guided group (4%) of patients than the 7-day

duration patients (1%) and the 14-day duration (2%) though numbers were small (13 patients total with C .Diff of the 164 total patients)

• No patients who received seven or fewer days of antibiotics got C. Diff

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Case #4 – Secondary Outcomes

• Patients who had implanted material or infections of pulmonary origin did worse• 21% of patients had implanted material (vast majority were small objects line

screws/pins)

• 7% of patients had a pulmonary source

• However, clinical failure in these patients was different at day 30 (results below statistically significant)• 7-day group: 18% had clinical failure at day 30

• 14-day group: 16% had clinical failure at day 30

• CRP group: no patients had failure at day 30

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Case #4 – Limitations

• Polymicrobial infections were excluded

• CRP levels were not scheduled but drawn per routine practice• This led to more protocol-duration violations which likely led to longer

treatment durations in the CRP group

• Low observed event rate which limits interpretation

• Wide range of treatment durations• Particularly in the CRP-group

• Study size relatively small

• Homogenous population that was 94% White (and Swiss)

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Case #4 – Take-Away Points

• A 7-day treatment course is non-inferior to a 14-day treatment course for uncomplicated gram-negative rod bacteremia

• CRP-guided therapy is non-inferior to a 14-day course of therapy though its utility beyond a fixed 7-day treatment course is unclear• May be helpful in patients who have implanted hardware or a pulmonary

source for their bacteremiaOHSU

Case #4 – How Long Should She Be Treated?

a) Stop antibiotics now (5-day total course)

b) 7-day total course

c) 10-day total course

d) 14-day total courseOHSU

Case #5

• Mr. D is a 75 yo man with a PMH significant for DM2 (A1c 7) and COPD who presents to the ER with fever, chills, RUQ pain and jaundice

• Vitals: T 101.3, BP 90/57, HR 115, R 20, O2 sat 96% on RA, Wt 100kg

• Exam: tachycardic, regular, RUQ TTP on exam

• Labs:• CBC: WBC 21

• Chem-7: Cr 1

• Liver panel: AST 185, ALT 175, T. Bili 4.5, Alk Phos 384

• Other: Procalcitonin of 2.5, CRP of 100

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Case #5

• CT A/P shows:• Cholelithiasis without e/o cholecystitis

• Dilated intra-hepatic ducts but no obstructing stone

• Given 2L LR with improvement in BP to 110/87 and HR to 98

• Started on Pip/Tazo and admittedOHSU

Case #5 – Hospital Days #1-4

• HD#1• Remains afebrile with improvement in BP to 137/89 and HR to 87• WBC declines to 14, T. Bili to 3.2, Alk Phos to 289• GI consulted and feel his clinical presentation is c/w a passed biliary stone.

Recommend MRCP and surgical consult• MRCP confirms cholelithiasis and mild ductal dilation without any biliary stones

present• Surgery consulted and plan for inpatient lap chole in a few days once he “cools off” a

bit

• HD#2-4• Blood cultures from the ER grow pan-sensitive E. Coli in both bottles; transitioned to

Ceftriaxone• WBC declines to 7, T. Bili 2.1, Alk Phos to 218, CRP to 20• Scheduled for lap chole on HD #6

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Case #5 – Hospital Day #5

• While you are on the ward seeing another patient, his nurse comes to get you• Tells you about five minutes prior he reported chills, started shaking and

became less responsive

• You go to the bedside as vital signs are being completed• T 102.9, BP 78/47, HR 132, RR 22, O2 sat 89% on RA• On exam he is awake and though less alert and more somnolent than when

you saw him earlier in the day. Also has more prominent RUQ pain on palpation

• EKG shows sinus tachycardia

• Rapid Response called and ICU transfer initiated

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Case #5 – What next?

• While awaiting transfer to the ICU, what other treatment should you order?

a) LR bolus

b) LR bolus + IV Hydrocortisone

c) LR bolus + IV Hydrocortisone + IV thiamine

d) LR bolus + IV Hydrocortisone + IV thiamine + IV Vitamin COHSU

Case #5: What we know

• Surviving Sepsis Guidelines from the Society of Critical Care Medicine continue to advise against using IV Hydrocortisone if adequate fluid resuscitation and vasopressor therapy can restore hemodynamic instability• Fluid resuscitation suggestion remains 30mL/kg of IV crystalloid within the

first three hoursOHSU

Case #5 – What we know

• The Marik trial published in 2017 created a lot of interest in the use of Vitamin C and Thiamine in sepsis• It was a small trial at a single center

• Control group was historical which has a high risk of biasOHSU

Case #5: Newer Data

• CITRIS-ALI published in JAMA in 2019 showed an improvement in 28-day mortality for patients with sepsis + ARDS who received high dose IV vitamin C• Secondary outcome analysis showed an improvement in 28-day morality that

was statistically significant (29.8% vs 43.6%)

• Buuuutttt

• The primary outcome was change in q-sofa score; no significant difference seen

• The secondary analysis looked at 46 possible outcomes and did not adjust for this so it could have been due to chance

• Also, they had ARDS so not super relevant to us

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Case #5: VITAMINS

• VITAMINS was a multi-center open label trial that compared IV Vitamin C + Thiamine + Hydrocortisone to just Hydrocortisone

• Patients were enrolled if they had septic shock for less than 24 hours

• Primary outcome was time alive and free of vasopressors• It found no difference between the two

• Secondary outcomes of note were mortality at 28 days, 90 days, in the ICU and in the hospital• No difference noted between them though not powered to detect them

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Case #5: VITAMINS

• Study limited by open label design, not tracking timing or duration of antibiotic administrationOHSU

Case #5: Take away points

• There is no role for IV Vitamin C or IV Thiamine in patients with septic shock

• IV fluid resuscitation with crystalloids (normal saline or LR) remain the treatment of choice• Volume: 30mL/kg in the first three hoursOHSU

Case #5 – What next?

• While awaiting transfer to the ICU, what other treatment should you order?

a) LR bolus (100kg * 30mL/kg = 3000mL over first three hours)

b) LR bolus + IV Hydrocortisone

c) LR bolus + IV Hydrocortisone + IV thiamine

d) LR bolus + IV Hydrocortisone + IV thiamine + IV Vitamin COHSU

Quick Hits – New antibiotics

• Omadacycline and Eravacycline are newer tetracyclines• Both have broad spectrum activity including MRSA

• Omadacycline has been FDA approved for CAP and SSTI

• Eravacycline currently being evaluated for use in complicated intra-abdominal infections and complicated UTIsOHSU

X50.0XXAOverexertion from strenuous movement or load, initial encounterOHSU

Objective

• Manage acutely decompensated heart failure according to the latest dataOHSU

Case #6

• Mr. E is a 75 yo man with a PMH significant for HFrEF (EF 30%), DM2 (A1c 7) and COPD who presents to the ER with two weeks of progressive shortness of breath

• Vitals: T 98.3, BP 126/87, HR 99, R 20, O2 sat 85% on RA->94% on 2L NC, Wt 100kg (220#)

• Exam: JVP elevated to the ear, bilateral crackles, 2+ BLE pitting edema

• Labs:• CBC: unremarkable

• Chem-7: Cr 2.1 (baseline Cr 1.3)

• Other: NT-proBNP 4573

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Case #6

• Cardiac Meds:• Atorvastatin 40mg PO QPM• ASA 81mg PO Daily• Furosemide 40mg PO BID• Lisinopril 10mg PO Daily• Metoprolol Succinate 50mg PO Daily

• Diabetes Meds:• Glipizide 10mg PO Daily• Metformin 1000mg PO BID

• COPD Meds:• Budesonide/Formterol• Albuterol MDI

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Case #6

• This is the patient’s fourth hospitalization in six months and each hospitalization typically takes 3-4 weeks to effectively diurese

• Cardiology was consulted by the ER and suggests you “really ramp of the vasodilation on this patient” and “max the Lisinopril early” to try and get him on optimal medical management

• Suggests you start the patient on nitropatch + SL NTG (for immediate effect while the nitro patch reaches steady state) + hydralazine 25mg PO q6h

• Then suggests you restart and up-titrate the Lisinopril in the next day or so with the goal of reaching the target dose of 40mg by discharge

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Case #6

• What do you do?a) Follow the suggested regimen

b) Do what you normally doOHSU

Case #6 - GALACTIC

• Multicenter, multinational RCT that looked at whether aggressive early and sustained vasodilation improved all-cause mortality and/or rehospitalization at 180 days in patients with acutely decompensated HF• Primary end-point: composite of all-cause mortality and rehospitalization

• Secondary end-points:• All-cause mortality

• Rehospitalization at 180 days

• Time to discharge

• BP on each day

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Case #6 – GALACTIC Patient Characteristics

• Patient population:• Non-pregnant adults with any EF who had NYHA class III or IV symptoms AND

a NT-proBNP>2,000

• Excluded patients who needed ICU level care, urgent angiogram, sBP<100 or Cr>2.8

• 781 patients included in the final analysis• ~1/3 women and half had EF<40%

• 29% had EF>50%

• Control group:• Usual care

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Case #6 – GALACTIC Intervention Arm

Day 1o SL NTG (or spray) 0.8mg q10 for 30mino Transdermal glyceryl trinitrate according to sBP:

40-60mg q24h if sBP<130 60-80mg q24h if sBP>130

o Oral Hydralazine 25mg PO q6ho After 6 hours, up-titration of transdermal glyceryl trinitrate according to sBP

+20-40mg q24h if sBP<130 +20-60mg q24h if sBP>130

Day 2o Up-titration of transdermal glyceryl trinitrate according to sBP

+20-40mg q24h if sBP 90-110 +20-60mg q24h if sBP 111-130 +40-80mg q24h if sBP>130

o Oral Hydralazine 25mg PO q6ho Initiation of ACE-I, ARB or ARN-I if not on already; up-titration of dose if they are

Day 3o Gradual reduction of transdermal glyceryl trinitrate according to sBP

50% of day 2 dose if sBP 90-130 75% of day 2 dose if sBP 131-150 100% of day 2 dose if sBP >150

o Up-titration of ACE-I, ARB or ARN-I therapy according to sBP Day 4

o Up-titration of ACE-I, ARB or ARN-I dependent on sBP until reaching maximum recommended daily dose

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Case #6 - GALACTIC

• Outcomes• Primary:

• No difference in the primary composite endpoint of all-cause mortality or rehospitalization at 180 days

• Secondary:• No significant difference in the key endpoints

• This included BP measurements on day 1 and day 3• The intervention group used statistically significantly higher doses of nitrates and statistically

significant lower doses of diuretics• At 180 days, more patients in the intervention group were on target doses of ACE-I, ARB or

ARN-Is• Women did worse in the intervention group

• Adverse events:• Rates of hypokalemia and AKI were similar though rates of hypotension and HA were

higher in the intervention group

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Case #6 – Take-away points

• There is no benefit from early aggressive and sustained vasodilation in patients with acutely decompensated heart failureOHSU

Case #6

• What do you do?a) Follow the suggested regimen

b) Do what you normally doOHSU

Quick Hit – GALACTIC-HF

• GALACTIC is not to be confused with GALACTIC-HF

• GALACTIC-HF is an ongoing phase 3 clinical trial (wrapping up soon) that compares Omecamtiv Mecarbil to placebo in patients with HFrEF• Omecamtiv Mercarbil is a novel selective cardiac myosin activator that

increases myosin contractility

• IV medication

• Large scale trial with more than 8,000 patients

• Should be published in 2021; possible sooner if an interim analysis shows benefit

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Y92.241Hurt at the libraryOHSU

One-Liner Take-Aways

• A higher D-dimer threshold of <1mcg/mL (1000ng/mL) can be used to exclude VTE in patients with low C-PTP (Wells score 0-4)

• Oral factor Xa inhibitors (Edoxaban, Rivaroxaban, Apixaban) are safe alternatives for treatment of VTE in patients who have cancer

• TAVR is non-inferior or superior to SAVR across all patient risk profiles

• There is no role for Tranexamic acid in the treatment of upper GI bleedingOHSU

One-Liner Take-Aways

• Both a CRP-guided treatment course and a fixed 7-day treatment course are non-inferior to a 14-day treatment course for uncomplicated gram-negative rod bacteremia

• Omadacycline and Eravacycline are newer tetracyclines you may see in use over the next year or so

• There is no role for early aggressive and sustained vasodilation in patients with acutely decompensated heart failureOHSU

Articles

• Diagnosis of Pulmonary Embolism with D-dimer adjusted to Clinical Probability

• VTE associated malignancy• CARAVAGGIO

• ADAM-VTE

• Systematic Review

• HALT-ITOHSU

Articles

• Uncomplicated GNR Bacteremia• Seven versus 14 days of antibiotic therapy

• CRP-guided Treatment Duration

• Vitamin C + Thiamine in sepsis• CITRIS-ALI

• VITAMINS

• GALACTICOHSU