#163 Hotcakes: Burnout, iron for heart failure, aspirin & VTE prevention

July 29, 2019 | By Sarah Phoebe Roberts

Keeping the cakes steamy in July 2019

Summary

The sun is shining, the cakes are hot, and the takes are even hotter. Welcome to our July 2019 Hotcakes episode! Join us as our beloved hosts Chris, Matt, Stuart and Paul share some of the latest practice-changing knowledge, news and research in medical science. Today’s discussion covers studies on the use of IV iron supplementation for heart failure, aspirin as VTE prophylaxis after arthroplasty, and the relationship between physician burnout and ability to address patients’ social determinants of health. Honorable mentions include a throwback to the life-changing magic of Pokémon GO.   

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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

Editor: Christopher Chiu MD, Emi Okamoto MD

Cover-Art: Matthew Watto MD

Time stamps

• 00:20 Disclaimer, intro
• 02:30 Clinic capacity, provider burnout, and social determinants of health
• 15:00 Iron deficiency and heart failure meta-analysis (Zhou et al., 2019)
• 17:15 Iron deficiency and stable heart failure RCT (Ponikowski et al., 2015)
• 19:00 Iron deficiency and decompensated heart failure RCT (Yeo et al., 2018)
• 26:00 Aspirin as VTE prophylaxis after arthroplasty
• 38:00 Honorable mention (Pokémon Go!)
• 39:00 Wrap-up and outro

Olayiwola JN, Willard-Grace R, Dubé K, et al. Higher Perceived Clinic Capacity to Address Patients’ Social Needs Associated with Lower Burnout in Primary Care Providers. Journal of Health Care for the Poor and Underserved. 2018;29(1):415-429. doi:10.1353/hpu.2018.0028 

Related:

1. Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening. JAMA Network Open – May 2019

What’s the clinical question? 

Professional ‘burnout’ is common among primary care providers (PCPs), whose patients often suffer from both medical and social needs (e.g. housing or food insecurity, unemployment, economic hardship). This study sought to assess the role PCPs’ ability to address their patients’ social needs had on providers’ self-reported burnout.    

Study design

A total of 359 PCPs (including attendings, residents, NPs and PAs) located in San Francisco, California completed a web-based survey on burnout and capacity to assist patients with their social needs. Survey items asked participants about specific symptoms of burnout (exhaustion, cynicism, low professional efficacy) and four specific questions had PCPs rate their ability to engage with, address and receive clinic support for patients with social needs. 

Bottom line?

Greater perceived clinic capacity and availability of resources to assist with social needs was a significant predictor of burnout. PCPs who reported having adequate support/resources for assisting patients with their social needs also reported more professional efficacy, lower exhaustion, and lower cynicism. 

Zhou X, Xu W, Xu Y, Qian Z. Iron Supplementation Improves Cardiovascular Outcomes in Patients with Heart Failure. Am J Med. March 2019. doi:10.1016/j.amjmed.2019.02.018

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

Heart failure and iron deficiency frequently co-occur. A significant body of research has been conducted regarding the effect of iron supplementation on cardiac function among adult patients diagnosed with both heart failure and iron deficiency (ID). 

Study design

The authors conducted a meta-analysis of 10 randomized controlled trials comparing the effects of iron supplementation versus placebo on a total of 1404 heart failure patients. 

Bottom line? 

Compared to placebo, iron supplementation significantly improved heart failure patients’ 6MWT results, incidence of hospitalization for heart failure, self-reported quality of life, LV ejection fraction, oxygen consumption, and serum levels of NT-proBNP and CRP.

Ponikowski P, Veldhuisen DJ, et al. Beneficial effects of long-term intravenous iron therapy with ferric carboxymaltose in patients with symptomatic heart failure and iron deficiency^†. Eur Heart J. 2015 Mar 14; 36(11): 657–668. 

What’s the clinical question?  

This study evaluated the long-term impact of intravenous ferric carboxymaltose (FCM) administration on morbidity and mortality in heart failure patients. The primary end-point was change in 6MWT distance from baseline to Week 24. Secondary endpoints (weeks 6, 12, 24, 36, and 52) included: (a) changes in NYHA Class, (b) Patient Global Assessment, (c) 6MWT distance, (d) Fatigue Score, (e) quality of life scores, (f) deaths, (e) hospitalizations (secondary to heart failure or all-cause).

Study design

301 adult patients with STABLE NYHA Class II/III heart failure and ID (serum ferritin <100 ng/mL or <300 ng/mL if transferrin saturation <20%) were randomly assigned 1:1 to receive FCM (dosed by weight and Hb at screening; mean=1500 mg) or an equivalent volume of 0.9% normal saline intravenously. Patients with an immediate need for transfusion were excluded. Subjects were stratified by site and Hb levels (subjects with Hb <12.0 g/dL vs. Hb ≥12.0 g/dL).

Bottom line?

Intravenous FCM significantly improved overall function (on 6MWT, Fatigue Score) and reduced the risk of hospitalization due to heart failure (7.6% in the FCM group vs 19.4% in the placebo group). Overall hazard ratio for heart failure hospitalization was 0.39 (0.19-0.82, p=0.009). Given the relatively low cost of iron infusion can significantly decrease the risk of a costly heart failure admission (over $9,000) and improve function, this is likely cost effective.

Yeo TJ, Yeo PSD, Hadi FA, et al. Single-dose intravenous iron in Southeast Asian heart failure patients: A pilot randomized placebo-controlled study (PRACTICE-ASIA-HF). ESC Heart Failure. 2018;5(2):344-353. doi:10.1002/ehf2.12250

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

Iron deficiency (ID) is common among patients with heart failure, and evidence suggests administration of intravenous ferric carboxymaltose (FCM) improves patients’ quality of life and ability to exercise. This study aims to examine the effects of intravenous iron on exercise capacity and quality of life among Southeast Asian patients with ID and acute decompensated heart failure.

Study design

Fifty adult patients hospitalized for decompensated heart failure and found to have ID (per authors, serum ferritin <300 ng/mL if transferrin saturation <20%) were randomly assigned to receive a single dose of either 1000 mg FCM or an equivalent volume of 0.9% normal saline intravenously. The primary study outcome was improvement in patients’ 6-minute walk test (6MWT) distance over the course of 12 weeks post-infusion. The secondary outcome of interest was self-reported quality of life.     

Bottom line?

Though the primary outcome (6MWT) at 12 weeks did not show a significant improvement, it was a smaller study size given the population of hospitalized patients with heart failure. FCM did correct iron deficiency in over 75% of patients with ID. More importantly was the safety analysis, showing no serious or severe drug-related adverse events.  

Putting it all together: Stuart’s Expert Opinion

Heart failure is a chronic inflammatory condition, and iron deficiency is a common comorbid condition. For patients with admissions for heart failure, prior to discharge he checks ferritin and transferrin saturation. They meet inclusion for iron deficiency with ferritin < 100 ng/ml OR ferritin < 300ng/ml with transferrin saturation < 20%. If they don’t meet inclusion criteria, he orders a send-out soluble transferrin receptor (sTfR) activity level used to calculate a ferritin index (sTfR / log ferritin), which can also suggest an iron deficiency state. This identifies patients who may benefit from IV iron (assuming no contraindications like infection), both from functional status and decreased heart failure admissions.

Rondon AJ et al. The Use of Aspirin for Prophylaxis Against Venous Thromboembolism Decreases Mortality Following Primary Total Joint Arthroplasty. J Bone Joint Surg Am. 2019. 

Accompanying editorials/related articles: 

1. Herman A. As Good as Current Evidence Can Get: Commentary on an article by Alexander J. Rondon, MD, MBA, et al.: The Use of Aspirin for Prophylaxis Against Venous Thromboembolism Decreases Mortality Following Primary Total Joint Arthroplasty. J Bone Joint Surg Am. 2019. 
2. NEJM JWatch on a JAMA Surgery 2018 study: https://www.jwatch.org/fw114683/2018/10/18/aspirin-noninferior-other-anticoagulants-knee
3. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) Trial. Lancet 2000.
4. Falck-Ytter et al. Prevention of VTE in orthopedic surgery patients: Clinical Practice Guidelines. Chest. 2012. 
5. Lassen et al. Apixiban vs enoxaparin for thromboprophylaxis after hip replacement. NEJM 2012. 
6. Upcoming: Comparative effectiveness of pulmonary embolism prevention after hip and knee replacement (PEPPER Trial). 

What’s the clinical question? 

Aspirin is commonly recommended to patients undergoing total joint arthroplasty (TJA) in order to reduce venous thromboembolism (VTE) risk. This study investigates the effectiveness of aspirin as a VTE prophylaxis method on reducing mortality among TJA patients. 

Study design

A total of 31,133 TJA patients from 2000 to 2017 at a single institution were included in this retrospective cohort study. Analyses were conducted comparing short-term (30 days) and long-term (one year) mortality between patients who did and did not receive aspirin as part of their prescribed VTE prophylaxis.   

Bottom line?

Patients who received aspirin as VTE prophylaxis had a significantly lower short- and long-term mortality rate compared to those who did not. Authors suggest this is likely from the cardioprotective effect of aspirin. This is a retrospective study with much heterogeneity (varied doses of aspirin, different VTE prophylaxis strategies used, long study period with multiple surgical and pharmacologic advances). The optimal strategy is still unknown.

Hot takes & honorable mentions 

Watanabe K, Kawakami N, Imamura K, et al. Pokémon GO and psychological distress, physical complaints, and work performance among adult workers: a retrospective cohort study. Scientific Reports. 2017;7(1):10758. doi:10.1038/s41598-017-11176-2

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. Develop a framework 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 the current literature on the following subjects: (1) The effect of clinic capacity for addressing patients’ social needs on self-reported burnout among primary care providers, (2) The effect of iron supplementation on iron-deficient heart failure patients’ cardiac function, and (3) Aspirin as VTE prophylaxis for patients undergoing total joint arthroplasty (TJA). 

Disclosures: 

The Curbsiders report no relevant financial disclosures.

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