David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
This study examines a new way of using hs-cTnI testing in patients with known, stable CAD. It showed that hs-cTnI testing identified a population of patients with a low likelihood of inducible ischemia on MPI as well as a low risk for adverse cardiac events over 3 years.
Although hs-cTnI levels below the 2.5 pg/mL cutoff had a high NPV, hs-cTnI levels above this cutoff exhibited poor positive predictive value (17% [CI 14% to 21%]), suggesting that this approach is best used to identify a subgroup of low-risk patients.
An editorialist noted that high-sensitivity troponin testing may be more useful than stress testing to predict the course of stable CAD but that the results need to be replicated and refined in larger studies.
The review concludes that for preventing stroke or systemic embolism, dabigatran and apixaban are superior to warfarin and rivaroxiban and edoxaban are similar to warfarin.
The review concludes that for terms of major bleeding rates, apixaban and edoxaban are superior to warfarin and rivaroxaban and dabigatran are similar to warfarin.
The treatment effects of DOACs seem to be consistent across various patient subgroups, including those with a history of stroke, patients receiving concomitant aspirin therapy, patients with heart failure, and those with paroxysmal (vs. persistent) AF.
The authors note the substantial limitations of indirect comparisons of medications and use of observational data to compare medication effects. They call for head-to-head randomized trials to compare the DOACs.
The diagnostic approach seems to be safe and effective in this patient population.
The use of D-dimer testing in this population appears to be beneficial. The contribution of lower limb venous Doppler testing is small but would be expected to eliminate the need for radiation exposure for a few women (positive for DVT in 7 of 395 women in which it was performed). The rate of inconclusive CT results was less than previously reported.
Editorialists note that the primary weakness of this approach is that it uses a pretest probability rule that has not been validated in pregnant women and suggest that it may be an important area for future research.
The main finding of this study is that a well-implemented computer decision-support system can change clinical behavior in ways that benefit patients and reduce cost.
Editorialists suggest that this intervention was successful because it simplified the otherwise complex process of selecting patients with PE that were appropriate for outpatient management.
Patients that were discharged home did not have an increase in adverse events compared with their hospitalized counterparts, strengthening the evidence that low-risk patients can be safely managed without hospitalization.
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Wesorick DH, Chopra V. Annals for Hospitalists - 18 December 2018. Ann Intern Med. ;169:HO1. doi: 10.7326/AFHO201812180
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Published: Ann Intern Med. 2018;169(12):HO1.
Cardiology, Coronary Heart Disease, Hospital Medicine.
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