#160 Hotcakes: E-cigarettes, UTIs, Heart Failure

July 10, 2019 | By Sarah Phoebe Roberts

The SCOPE co-editor, Armand Gottlieb MD joins to discuss E-cigs vs nicotine replacement; UTIs in older adults; ARNIs for Heart Failure

Confession: we have been holding out on you. Specifically, we’ve been sitting on a special episode of Hotcakes and Hot Takes that we recorded this March, with featured guest Armand Gottlieb, MD of the online publication The Scope. But here it is! We hope you’ll enjoy our discussion of topics like the ever-controversial e-cigarette smoking cessation question, outcomes related to antibiotic treatment of UTIs among elderly adults, and the role of sacubitril-valsartan for acute decompensated heart failure in inpatient settings (the PIONEER-HF study).  Special guest is Dr. Armand Gottlieb @ArmandGottlieb, who was a third year internal medicine resident at Columbia University Medical Center in New York City at the time of recording. He is a co-Editor of the The Scope, a free and brief weekly roundup of the most recent and relevant medical literature.

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Credits 

• Written and Produced by: Sarah Phoebe Roberts MPH, Christopher Chiu MD
• Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD, and Christopher Chiu MD
• Guest Presenter and Content Planning: Armand Gottlieb, MD
• Editor: Christopher Chiu MD
• Cover-Art: Christopher Chiu MD

Pick of the Week

Time stamps

• 01:00 Disclaimer, intro, guest bio
• 06:30 E-cigarettes vs. nicotine replacement therapy (NRT)
• 15:50 Antibiotic treatment of urinary tract infections (UTIs)
• 27:45 Sacubitril-valsartan for acute decompensated heart failure (PIONEER-HF study)
• 42:30 Wrap-up and outro

The Hottest of Cakes and the Hottest of Takes

Hajek P, Phillips-Waller A, Przulj D, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. New England Journal of Medicine. 2019;380(7):629-637. doi:10.1056/NEJMoa1808779

This website is amazing: https://www.blu.com/en/US/explore/explore-vaping/e-liquid/what-is-e-liquid 

Note: Study summary is excerpted from the February 15, 2019 issue of The Scope. Read the full summary and issue here. 

What’s the clinical question? Who is the patient population?

E-cigarettes are by all means a public health crisis: rates of use are exploding among teens despite unknown long-term health consequences and high potential for addiction. Stats aside, public health experts believe e-cigarettes are safer than combustible tobacco, and US smokers are more likely to try e-cigarettes than FDA-approved smoking cessation aides when they try to quit. 

Study design

The UK National Health Service compared traditional nicotine replacement therapy (NRT) to refillable e-cigarettes in ~900 smokers who sought help quitting. Both groups received behavioral counseling, and abstinence was confirmed with carbon monoxide testing. One year abstinence rates were 18% in the e-cigarette group compared with 10% in the NRT group, yet 80% of abstinent e-cigarette users continued to vape while only 9% of NRT patients stuck with their product. For comparison, abstinence rates following NRT + bupropion (20% at 1 year) or varenicline (26% at 24 weeks) were similar.

Bottom line?

If your patients want to break their nicotine addiction, there are better options out there than e-cigarettes. Vaping looks like a good fit for those who want to replace one habit with another.

Gharbi M, Drysdale JH, Lishman H, et al. Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study. BMJ. February 2019:l525. doi:10.1136/bmj.l525

See also: NICE Guidelines on Cystitis (non-catheterized patients) 

What’s the clinical question? Who is the patient population?

Compared to treatment with antibiotics, what effect does deferred or no antibiotic treatment for UTIs have on the rate of bloodstream infection, hospitalization and all-cause mortality among outpatient elderly adults?

Study design 

Retrospective cohort study of medical and death records for 157,254 adults aged 65+ who presented to general practitioners in England with suspected or confirmed lower UTI. Data were collected between November 2007 and June 2015. Patients were categorized as follows, with respect to when they received treatment: 1. Immediate antibiotics (prescribed same day) 2. Deferred antibiotics (prescribed within seven days of diagnosis) and 3. No antibiotics (no antibiotic prescription on record after seven days post-diagnosis). The primary outcomes were bloodstream infection and all-cause mortality within 60 days post-UTI diagnosis.

Bottom line?

Patients in the deferred and no-antibiotics groups were significantly more likely to experience a bloodstream infection compared to patients who were immediately prescribed antibiotics, even after controlling for covariates such as age and sex. Additionally, patients in the deferred and no-antibiotics groups had a significantly higher rate of all-cause mortality within 60 days post-UTI. These findings were particularly pronounced for male patients aged 85+. 

Velazquez EJ, Morrow DA, DeVore AD, et al. Angiotensin–Neprilysin Inhibition in Acute Decompensated Heart Failure. New England Journal of Medicine. 2019;380(6):539-548. doi:10.1056/NEJMoa1812851

Note: Study summary is excerpted from the December 7, 2018 issue of The Scope. Read the full summary and issue here. 

What’s the clinical question? Who is the patient population?

Your brain can do fancier things than dose diuretics during run-of-the-mill heart failure hospitalizations, but it’s nice to stay in your comfort zone. Can an outpatient med shake up the routine? It’s as tiring as it is tried and true: admit, diurese, repeat. Basic inpatient heart failure management hasn’t changed in decades despite a slew of failed trials. The ideal med would unload the heart by dropping afterload, increasing salt excretion, and dampening sympathetic tone. Sacubitril-valsartan (Entresto) – an outpatient winner following 2014’s PARADIGM-HF – mechanistically fits the bill, but inpatients were excluded from the landmark 2014 study. It was only a matter of time until the medication was put to the test on the wards.   

Study design

PIONEER-HF compared sacubitril-valsartan to placebo in 880 patients admitted with acute decompensated heart failure (ADHF). The trial met its biomarker-driven primary outcome by reducing NT-proBNP levels compared to placebo after 8 weeks. More impressive were results from a prespecified clinical composite outcome: the rate of rehospitalization, death, or listing for transplant was 9% in the treatment group and 16% for placebo, a 45% relative risk reduction in the trial’s brief intervention period.  

Bottom line? 

Though longer-term follow-up will be watched closely, these results could very well be practice changing. Sacubitril-valsartan supporters think that starting the med in the hospital will also prompt greater use in the outpatient setting.

Goals and Learning Objectives

Goals 

Listeners will learn about relevant medical literature, with emphasis on breaking news and recently published research. 

Learning objectives

After listening to this episode listeners will…

1. Learn about important journal articles and their salient points
2. Learn how to critically analyze journal articles in a practical way
3. Learn what medical news is being widely reported in the lay media and the underlying evidence in the literature
4. Review recent literature on the following subjects: (1) The effect of electronic cigarette use on smoking cessation, (2) Infection and mortality outcomes among elderly adults prescribed immediate, deferred or no antibiotic treatment for UTIs, (3) The evidence for sacubitril-valsartan as treatment for inpatient adults with acute decompensated heart failure (ADHF)

Disclosures 

Dr. Gottlieb reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Tags

E-cigarettes, smoking, cessation, nicotine, tobacco, vape, addiction, UTI, antibiotics, infection, cardiac, cardiovascular, MI, heart failure, sacubitril, valsartan, resuscitation, perfusion, lactate, sepsis, shock, blood, treatment, mortality, assistant, care, elderly, patient, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student

Citation

Gottlieb, Armand. Guest presenter, content planner. “#160 Hotcakes: E-cigarettes, UTIs and Heart Failure.” The Curbsiders Internal Medicine Podcast http://thecurbsiders.com. July 10, 2019.