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Annals for Hospitalists - 20 September 2016Annals for Hospitalists - 20 September 2016 FREE

David H. Wesorick, MD; and Vineet Chopra, MD, MSc
[+] Article, Author, and Disclosure Information

From University of Michigan, Ann Arbor, Michigan.

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.

Ann Intern Med. 2016;165(6):HO1. doi:10.7326/AFHO201609200
© 2016 American College of Physicians
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by Geoffrey D. Barnes, MD, MSc, and David Paje, MD

For the first time in history, clinicians can choose from several oral anticoagulant drugs other than warfarin. This article offers perspective on the expanding choices and what they mean for hospitalists and their patients.

Ann Intern Med. 2016;165:334-44. Published online 7 June 2016. doi:10.7326/M16-0060

This systematic review and meta-analysis reviews 5 randomized trials and 31 observational studies (all with matched designs) to evaluate outcomes for more than 16 000 patients treated with transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR). The meta-analysis found no statistically significant difference in early (30-day) or midterm (1-year) mortality between TAVI and SAVR, regardless of patient risk.

Key points for hospitalists include:

  • Although originally studied only in patients with prohibitive surgical risk, there is now evidence that TAVI results in early and midterm mortality rates that are at least as good as SAVR, even in some patients with low or intermediate surgical risk.

  • More data are needed to understand longer-term outcomes, because the durability of the TAVI prosthesis is uncertain. However, with increased experience, technological improvements, and availability of longer-term data, TAVI may begin to play a larger role in the treatment of patients with aortic stenosis.

  • TAVI and SAVR are associated with different complications. The incidence of periprocedural myocardial infarction, major bleeding, acute kidney injury, and new-onset atrial fibrillation is higher with SAVR, but pacemaker implantation, vascular complications, and paravalvular leak occur more commonly with TAVI.

Ann Intern Med. 2016;165:390-8. Published online 5 July 2016. doi:10.7326/M15-2762

This retrospective cohort study from Denmark compares the incidence of Staphylococcus aureus bacteremia (SAB) in persons who have a first-degree relative with a history of SAB (n = 34 774) with the incidence of SAB in the population in general. The main finding of the study is that persons with a first-degree relative with a history of SAB have a higher incidence than people in the general population.

Key points for hospitalists include:

  • Familial clustering suggests that genetic factors influence risk for SAB.

  • The magnitude of the increased risk for patients with first-degree relatives with SAB is small compared with that of other known risk factors (e.g., HIV, diabetes, cancer, intravenous drug use, and catheter placement).

  • Although the immediate clinical implications of this finding are unclear, genetic factors placing hosts at increased risk for infection are of growing interest and may play a role in diagnosis, evaluation, and treatment of common clinical conditions.

For treatment of severe aortic stenosis, how do outcomes between TAVR and SAVR compare after 2 years of follow-up in patients with intermediate surgical risk?

Ann Intern Med. 2016;165:JC21. doi:10.7326/ACPJC-2016-165-4-021

This randomized, controlled trial (n = 2032) examined death or disabling stroke for patients treated with TAVR (balloon-expandable SAPIEN XT heart-valve system) compared with those treated with SAVR. The study found that TAVR was noninferior to SAVR in this intermediate-risk population.

In patients receiving antiplatelet therapy, should intracranial hemorrhage be treated with platelet transfusion?

Ann Intern Med. 2016;165:JC19. doi:10.7326/ACPJC-2016-165-4-019

This randomized, controlled trial (n = 190) examined the effect of platelet transfusion versus standard care in treating patients with ICH who were also receiving antiplatelet medications. It found that random assignment to platelet transfusion did not influence expansion of hemorrhage in the first 24 hours. However, transfusion was associated with increased rates of death and dependence at 3-month follow-up.

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