#393 Live from SHM: Clinical Updates in Hospital Medicine

May 1, 2023 | By Rahul Ganatra

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Join us for this Hotcakes style episode as we talk through impactful literature for the hospitalist with Dr. Heather Nye (UCSF) and  Dr. Rahul Ganatra (@rbganatra, Harvard University) who presented the Clinical Updates in Hospital Medicine at SHM #Converge23. 

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Show Segments

• Intro, disclaimer
• Rapid fire questions/Picks of the Week
• EMPULSE
• ADVOR
• STRONG-HF
• CRISTAL
• Perioperative Gabapentin
• Waterfall
• Midline catheters vs PICC lines
• What’s in a Name?
• Outro

Hotcake #1: EMPULSE (Rahul)

Voors AA, Angermann CE, Teerlink JR, et al. The SGLT2 inhibitor empagliflozin in patients hospitalized for acute heart failure: a multinational randomized trial. Nat Med. 2022;28(3):568-574.

What was the research question? Should SGLT2 inhibitors be started during hospitalization for acute heart failure?  

How was the study done? 530 adults hospitalized with acute heart failure were randomized to receive empagliflozin or placebo in addition to usual care. All patients had dyspnea and clinical, laboratory, and imaging evidence of congestion, were hemodynamically stable, and could not have PE, MI, or ESRD, among others.

Top-line results: Patients randomized to empagliflozin were 36% more likely to have clinical benefit at day 90. This was driven by greater improvement in symptoms and greater diuretic response.

Limitations & Learning Points: This study used a measure of association called the win ratio, which is a little complex, but enables use of a hierarchical composite outcome. Using this, we are able to determine that the major benefit of empagliflozin in these patients is improvement in symptoms. Further reading: https://pubmed.ncbi.nlm.nih.gov/21900289/  

Bottom line: Start empagliflozin in patients hospitalized with acute heart failure to improve outcomes as early as 15 days later.

Hotcake #2: ADVOR (Rahul)

Mullens W, Dauw J, Martens P, et al. Acetazolamide in acute decompensated heart failure with volume overload. N Engl J Med. 2022;387(13):1185-1195.

What was the research question? Does adding acetazolamide to loop diuretics lead to faster decongestion in acute heart failure?

How was the study done? 519 adults hospitalized with acute heart failure were randomized to receive acetazolamide 500 mg IV daily or placebo in addition to a standard loop diuretic protocol. Patients had to be on a loop diuretic as an outpatient, and patients on SGLT2 inhibitors were excluded. 

Top-line results: Patients randomized to acetazolamide were 46% more likely to be euvolemic at day 3. In absolute terms: 12% more patients were euvolemic at day 3 (NNT = 8).

Limitations & Learning Points: This study does not prove that acetazolamide is better than more loop diuretics. Also, patients on SGLT2 inhibitors were excluded, and this was tested in a homogenous population. Nevertheless, this adds to the evidence base for sequential nephron blockade.

Bottom line: Among patients hospitalized with acute heart failure, adding acetazolamide to loop diuretics increases decongestion by day 3.

Hotcake #3: STRONG-HF (Heather)

Mebazaa A, Davison B, Chioncel O, et al. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (Strong-hf): a multinational, open-label, randomised trial. The Lancet. 2022;400(10367):1938-1952.

What was the research question? Is rapid up-titration of GDMT for acute heart failure safe and effective?

How was the study done? 1,085 patients hospitalized with acute heart failure who were not on optimal GDMT were randomized to usual care or high-intensity care (in-hospital initiation and rapid uptitration of beta blockers, ACE/ARB/ARNIs, and MRAs over the next 2 weeks). 

Top-line results: Rapid up-titration of GDMT (with close monitoring) led to a 34% reduction in all-cause death or heart failure readmissions at 180 days, an absolute risk reduction of 8.1% (NNT = 13).

Limitations & Learning Points: Adverse events were more common in the high-intensity group, but these were mostly hypotension, hypokalemia, and AKI. The primary outcome was changed after protocol registration, but this was unlikely to have biased towards a positive result. SGLT2 inhibitors were not included in this study, and the follow-up the high-intensity group received was very resource-intensive. 

Bottom line: Initiate a plan for rapid up-titration of GDMT for heart failure in the inpatient setting with close outpatient follow-up to reduce readmissions and mortality. 

Hotcake #4: CRISTAL(Heather)

Sidhu VS, Kelly TL, et al. Effect of aspirin vs enoxaparin on symptomatic venous thromboembolism in patients undergoing hip or knee arthroplasty: the cristal randomized trial. JAMA. 2022;328(8):719-727.

What was the research question? Is aspirin as effective as low molecular-weight heparin in prevention of VTE following knee and hip arthroplasty?

How was the study done? This was a cluster-randomized crossover trial done at 31 hospitals in Australia from 2019-2021. 9,711 people undergoing elective THA or TKA for OA were included. 

Top-line results: LMWH was superior to aspirin monotherapy in preventing symptomatic VTE following THA/TKA at 90 days (1.8% vs 3.5%) without any difference in bleeding.

Limitations & Learning Points: Below-knee DVTs drove the primary outcome (less clinically significant than above-knee DVTs). Of note, the International Consensus Meeting on VTE Guidelines in 2022 recommend aspirin for DVT prophylaxis in all patients; likely due to cost and convenience. 

Bottom line: In TKA/THA patients at higher risk for VTE, consider using LMWH instead of ASA for VTE prophylaxis.

Hotcake #5: Perioperative Gabapentin (Heather)

Park CM, Inouye SK, Marcantonio ER, et al. Perioperative gabapentin use and in-hospital adverse clinical events among older adults after major surgery. JAMA Internal Medicine. 2022;182(11):1117-1127.

What was the research question? Is gabapentin use among older adults after major surgery safe?

How was the study done? This was a retrospective cohort study including 230,000 patients over age 65 who underwent major surgery from 2009-2018. 

Top-line results: Perioperative gabapentin use was associated with increased risk of delirium after surgery (3.4% vs 2.6%). Rates of pneumonia and antipsychotic use were also higher, but the absolute risk differences were small.   

Limitations & Learning Points: Residual confounding and underdiagnosis of delirium are two sources of bias in this study (rates of delirium in similar populations in other studies are closer to 15-25%). Despite small effect sizes, a dose-response relationship with increasing gabapentin doses was observed, and sensitivity analyses suggest that confounding by severe pain does not fully explain the results.

Bottom line: Perform a careful risk-benefit assessment before routinely prescribing gabapentin for perioperative pain management to older patients.

Further Reading:

• Anesthesia Guidelines for Perioperative Pain Management

Hotcake #6: WATERFALL (Heather)

de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or moderate fluid resuscitation in acute pancreatitis. N Engl J Med. 2022;387(11):989-1000.

What was the research question? Does early aggressive fluid resuscitation improve outcomes in acute pancreatitis?

How was the study done? This was a multicenter, open-label randomized superiority trial done at 18 centers.  249 patients admitted with acute pancreatitis were included; patients with severe moderate or severe disease were excluded and those at high risk for volume overload (e.g. decompensated CHF or cirrhosis) were excluded. The study was stopped early for harm.

Top-line results: Early aggressive IVF resuscitation did not prevent complications of pancreatitis, but did lead to a higher risk of volume overload (20.5% vs 6.3%).

Limitations & Learning Points: The findings of this study suggest an update to professional society guidelines, which in the case of acute pancreatitis are based on low-quality evidence, is due. 

Bottom line: For patients with mild acute pancreatitis, use a modest fluid resuscitation strategy (boluses of 10 cc/kg in patients with hypovolemia only, and no boluses when euvolemic) and maintenance fluids at 1.5 cc/kg/hour over an aggressive resuscitation strategy. 

Hotcake #7: Midline vs PICC line (Rahul)

Swaminathan L, Flanders S, Horowitz J, Zhang Q, O’Malley M, Chopra V. Safety and Outcomes of Midline Catheters vs Peripherally Inserted Central Catheters for Patients with Short-term Inidcations: A Multiceneter Study. JAMA Internal Medicine. 2022; 182(1):50-58.

What was the research question? Are midlines better than peripherally inserted central catheters (PICC)? 

How was the study done? This was a retrospective cohort study utilizing data from a multihospital registry. They compared patients who had midline catheters placed against patients who had PICC lines placed for the specific indications of difficult venous access or intravenous antibiotic therapy for less than 30 days. 

Top-line results: PICC lines were associated with twice the odds of major complications compared to midlines. The odds of bloodstream infection were about four times higher with PICC lines. The odds of occlusion were two times higher with PICC lines.

Limitations & Learning Points: As an observational study, there is unmeasured confounding which could affect conclusions. While the study design can show associations, it does not necessarily demonstrate causation. Further studies with RCTs are necessary to confirm results from this study. 

Bottom line: Use midlines instead of PICCs to reduce risk of complications in patients needing extended IV access. 

Hotcake #8: What’s in a Name? (Rahul and Heather)

Hause E, Praska C, Pitt MB, et al. What’s in a name? Laypeople’s understanding of medical roles and titles. Journal of Hospital Medicine. 2022;17(12):956-960.

What was the research question? Does the public understand what a hospitalist does?

How was the study done? A cross sectional survey was performed at the 2021 Minnesota State Fair and included 204 English speaking adults over the age of 18. They sought to assess the public’s understanding of medical specialties and seniority of an academic team. 

Top-line results: Hospitalist role was correctly identified by only 31%. Attendings only categorized as MOST experienced 27% of the time. 

Limitations & Learning Points: Homogenous, small sample size which may not be representative of the country as a whole. 

Bottom line: Hospistalists need to take time to communicate their role to patients’ and families about their role and the individual team members’ role. 

Links

1. Amy’s Ice Cream
2. Austin, TX Bats 

Goal

Listeners will review recent practice-changing articles and medical news.

Learning objectives

After listening to this episode listeners will…  

1. Determine the risk of aggressive fluid resuscitation in mild acute pancreatitis. 
2. Explore the benefit of early GDMT in the hospitalized patient.
3. Review the risks of gabapentin during the perioperative period. 
4.  Compare and contrast benefits of aspirin to LMWH for VTE prophylaxis in TKA/THA patients. 

Disclosures

Dr. Nye and Dr. Ganatra report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Amin M, Trubitt M, Ganatra R, Nye H. “#393: Live from SHM: Clinical Updates in Hospital Medicine”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date May 1, 2023.