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November 19, 2013 Issue

Clinical Practice Points

Practice Based Learning and Improvement
Interpersonal and Communication Skills

Association Between Exposure to Low to Moderate Arsenic Levels and Incident Cardiovascular Disease. A Prospective Cohort Study

This study found that long-term exposure to low to moderate levels of arsenic, likely found in drinking water, was correlated with higher risk for fatal and nonfatal cardiovascular events.

Use this study to:

  • Review the concept of causality.
  • Pose the following question to your learners: What if your patient brought you this article and demanded to have his or her urine tested for arsenic? Refer to ACP HVC Curriculum Module One on Eliminating Health Care Waste and Over-ordering of Tests to frame your discussion.
  • Use the accompanying editorial to help identify important considerations regarding applying these findings.

Medical Knowledge

Comorbidity-Adjusted Life Expectancy: A New Tool to Inform Recommendations for Optimal Screening Strategies

This study estimated life expectancy of Medicare beneficiaries with and without comorbid conditions. Life expectancies at age 75 years were about 3 years shorter with high comorbidity and longer without. Comorbidity-adjusted life expectancy could help physicians tailor cancer screening recommendations.

Use this article to:

  • Review age-appropriate cancer screening and discuss the recommendations around discontinuing screening.
  • Explore barriers to appropriate utilization of screening tests in patients—these are discussed in a recent article.

Teaching on the Fly and Bedside Pearls


Patient Care

Comparative Safety of Vascular Closure Devices and Manual Closure Among Patients Having Percutaneous Coronary Intervention

This study found fewer hematomas and pseudoaneurysms but more retroperitoneal bleeding events when vascular closure devices were used after percutaneous coronary intervention. Patients with a low body mass index and those treated with glycoprotein IIb/IIIa inhibitors did not benefit from vascular closure devices compared with manual closure.

Use this article to:

  • Have a multiple-choice question ready to use on your smart phone for when you encounter an appropriate patient during rounds—we’ve provided one below.
  • Teach at the bedside of a patient who is scheduled for or just underwent cardiac catheterization. Discuss possible complications of catheterization and review physical examination findings associated with pseudoaneurysms and retroperitoneal bleeding.
  • Use the information in ACP Smart Medicine’s Percutaneous Coronary Interventions to review periprocedural management, examination findings, and more.
  • Ask your learners whether they’d recommend a vascular closure device for that patient based on the findings in this article.

Clinical Guideline


Medical Knowledge
Interpersonal Communication Skills

Medications for Risk Reduction of Primary Breast Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement

The USPSTF recommends against the routine use of medications for the prevention of breast cancer in women who are not at increased risk. They recommend shared decision making for the use of these medications in women who are at increased risk for breast cancer.

Use this article to:

  • Discuss the risk factors for breast cancer and prevention strategies in women who are at high risk. Use the "Population at Risk" tab in ACP Smart Medicine's Screening for Breast Cancer to review risk factors.
  • Teach communication strategies for shared decision making with your patients. Read a recent article that lists 5 steps to engage patients in these crucial discussions.

ACP Journal Club

Select articles chosen for their methodological rigor and clinical importance to discuss in a journal club. http://annals.org/journalclub.aspx


mksap16

A 70-year-old woman is evaluated in the coronary care unit for right groin pain 8 hours after undergoing angioplasty and stent placement for an inferior wall ST-elevation myocardial infarction. During the procedure, she developed transient bradycardia and required placement of a temporary transvenous pacemaker through the right femoral vein. Medical history is significant for gout treated with allopurinol and type 2 diabetes mellitus treated with glyburide. Additional medications are aspirin, eptifibatide, clopidogrel, and simvastatin.

Blood pressure is 130/80 mm Hg, heart rate is 72/min, and respiration rate is 12/min. Physical examination is notable for a 12- by 12-cm area of fullness at the right groin puncture site that is tender to palpation. Auscultation over the groin puncture site is notable for a continuous bruit. The dorsalis pedis and posterior tibial pulses are 2+ bilaterally and the right foot is warm. A stat hematocrit is 39%.

Which of the following is the most appropriate management?

A. Ankle-brachial index
B. CT
C. Duplex ultrasonography
D. Lower-extremity angiography

Correct Answer
C. Duplex ultrasonography

Key Point
Duplex ultrasonography is the optimal method to differentiate between a pseudoaneurysm and an arteriovenous fistula in patients with a vascular complication following percutaneous coronary intervention.

Educational Objective
Evaluate a patient with a vascular complication following percutaneous coronary intervention.

This patient who underwent a percutaneous coronary intervention (PCI) several hours ago should be evaluated with duplex ultrasonography for a possible pseudoaneurysm or arteriovenous fistula. She has pain at the site of placement of the arterial and venous sheaths. On examination, a large mass is palpated and is associated with a continuous bruit. These findings suggest either a pseudoaneurysm or an arteriovenous (AV) fistula. Vascular complications occur in fewer than 6% of patients undergoing PCI and include hematoma formation at the arterial puncture site, pseudoaneurysm, arteriovenous fistula, cholesterol emboli syndrome, and retroperitoneal bleeding. Duplex ultrasonography is the optimal method to differentiate between a pseudoaneurysm and an AV fistula and determine whether endovascular or surgical intervention is required.

An ankle-brachial index (ABI) would not add to the management of the patient presented. A normal ABI in this patient would not exclude a pseudoaneurysm or AV fistula. A low value would suggest the presence of preexisting peripheral vascular disease but would not assist in defining the problem.

CT is most often required after cardiac catheterization if there is a suspicion of a retroperitoneal bleed, which usually results from a proximal puncture of the common femoral artery in the setting of ongoing anticoagulation. Patients often present with flank or back pain and persistent hypotension. CT is useful to establish the diagnosis, but patients are often too ill to be transferred for CT scanning. Given that the patient presented has groin pain, the possibility of a retroperitoneal bleed is unlikely.

Lower-extremity angiography may occasionally be useful when complications occur following cardiac catheterization in the setting of diminished distal pulses if there is a concern for dissection of the common femoral artery or distal embolization. When this occurs, access can be obtained in a contralateral location and angiography used to confirm vessel dissection or occlusion of distal vessels. Angioplasty and endovascular stent placement may be required. This patient's distal pulses are normal, and lower-extremity angiography is not needed.

Bibliography
Applegate RJ, Sacrinty MT, Kutcher MA, et al. Trends in vascular complications after diagnostic cardiac catheterization and percutaneous coronary intervention via the femoral artery, 1998 to 2007. JACC Cardiovasc Interv. 2008;1(3):317-326. PMID: 19463320

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.


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