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September 1, 2015 Issue

Clinical Practice Points

Medical Knowledge
Patient Care

Visit-to-Visit Variability of Blood Pressure and Coronary Heart Disease, Stroke, Heart Failure, and Mortality. A Cohort Study

Variability in blood pressure (BP) measurements across outpatient visits is frequently viewed as random fluctuation without clear prognostic importance. This study found that higher visit-to-visit variability of systolic blood pressure readings is associated with an increased risk for cardiovascular disease and mortality.

Use this study to:

  • Start a teaching session with multiple-choice questions. We've provided two below!
  • Ask if your learners have ever ordered ambulatory BP monitoring to assess patients for masked hypertension, or to evaluate control among those already receiving therapy. Do they know how to arrange such testing?
  • Review how a cohort study design works. Ask your leaners what the “exposure” was in this study. Look at Figure 1 to help illustrate when the exposure (visit-to-visit variability in BP) and outcomes (cardiovascular events and all-cause mortality) during follow-up were assessed.
  • Do your learners think the results of this study should alter their current practice? Why or why not? Ask how they would design a randomized, controlled trial to assess whether reducing variation in visit-to-visit BP would alter the risk for cardiovascular outcomes.

Patient Care
Interpersonal / Communication Skills
Practice-based Learning / Improvement

How to Monitor Patients Receiving Direct Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Practice Tool Endorsed by Thrombosis Canada, the Canadian Stroke Consortium, the Canadian Cardiovascular Pharmacists Network, and the Canadian Cardiovascular Society

Direct oral anticoagulants (DOACs) are making anticoagulation simpler for patients with atrial fibrillation who need protection from strokes. However, clinicians still have an important role to play in patient monitoring to ensure that these drugs are used as safely and effectively as possible. The authors of this guide provide a framework for monitoring patients receiving these drugs.

Use this paper to:

  • Ask your learners how the advantage of not requiring blood work to monitor INR is also a potential safety issue with the use of DOACs.
  • Review with your learners how apixaban, dabigatran, edoxaban, and rivaroxaban work. Review the conditions for which they are approved.
  • Ask why a missed DOAC dose might be riskier than a missed dose of warfarin. The authors explain why the shorter half-lives of the DOAC may increase the risk for devastating strokes if doses are missed. What drug–drug interactions might occur?
  • The authors note that patients' understanding of the rationale for adherence to treatment is essential. Ask your learners to demonstrate how they would explain the rationale to a patient. A video reviews what needs to be explained to patients about the risk for stroke with atrial fibrillation (see “White Board Video Presentations—Patient Care”).
  • Review the “A, B, C, D and E” of monitoring patients receiving DOACs.
  • The authors propose a checklist to use in assessing patient adherence and safety with DOACs. Review this list with your learners and ask if they think it would be helpful in their practices. How might they plan to study whether their practices monitor patients receiving anticoagulant therapy (with warfarin or DOACs) appropriately? Can such a quality assessment be performed readily within your practice?

Medical Knowledge
Patient Care

In the Clinic: Carpal Tunnel Syndrome

Compressive median neuropathy at the wrist (“carpal tunnel syndrome”) is the most common entrapment neuropathy, and it is estimated to occur in up to 3.8% of the general population. This concise and practical review discusses key topics your learners need to know to evaluate and care for their patients.

Use this review to:

  • Review the symptoms and physical findings of patients with carpal tunnel syndrome. Review the distribution of the median nerve (see the figure in the review).
  • Ask your learners what other diagnoses should be considered in patients with wrist and/or arm discomfort. When are nerve conduction or electromyography studies needed? Are other tests indicated?
  • What therapies are to be considered, and how effective are they? When should a patient be sent to a specialist?
  • Break up a teaching session with the multiple-choice questions provided to introduce key teaching points. Don't forget to log on and enter your responses to claim CME for yourself.
  • Download the already-prepared slides to aid in preparing a teaching session.

Humanism and Professionalism


Annals Graphic Medicine

Annals Graphic Medicine: Doctor and Patient

Amrita Mukhopadhyay, a medical student, examines the modern-day physician–-patient interaction. Ask your learners how these interactions are changing. Which changes are good, and which ones bad? Do we have realistic, or unrealistic, expectations of medical care? Of ourselves as physicians?

Teaching Scholarship Opportunity


Patient Care
Practice Based Learning

Herbert S. Waxman Clinical Skills Center Teaching Scholarship

Chief residents who are ACP members are eligible to apply for a Herbert S. Waxman Clinical Skills Center Teaching Scholarship. The Waxman Center is part of ACP’s annual Internal Medicine Meeting, and it provides hands-on, small-group learning opportunities for clinical and procedural skills. Waxman Scholars help teach popular workshops under the guidance and mentorship of expert faculty. Eligible workshops include ultrasound-guided invasive procedures (central line, paracentesis, and lumbar puncture), arthrocentesis, and incision and drainage of abscesses. The scholarship includes the cost of meeting registration, travel, and accommodations for the selected chief residents to attend the ACP Internal Medicine Meeting 2016 from May 5-7, 2016, in Washington, DC.

The application window is from 9/1/15 to 10/9/15.

Only chief residents who are ACP Resident/Fellow Members are eligible to apply. Eligible chief residents can access the application by logging into ACP Chief Resident's Corner.


Question 1

A 54-year-old woman is evaluated for an abnormal electrocardiogram obtained at a local health screening fair. She has no cardiovascular symptoms or risk factors and takes no medications.

On physical examination, blood pressure is 136/80 mm Hg; other vital signs are normal. The remainder of the examination is unremarkable.

Laboratory studies, including complete blood count, serum creatinine, electrolytes, and lipids, are normal.

The electrocardiogram demonstrates voltage criteria for left ventricular hypertrophy. A follow-up echocardiogram confirms the presence of symmetric left ventricular hypertrophy without evidence of aortic valve disease or resting outflow gradient.

Which of the following is the most appropriate next step in management?

A. 24-Hour ambulatory blood pressure monitoring
B. Cardiac MRI
C. Chlorthalidone
D. Coronary artery calcium score

Correct Answer
A. 24-Hour ambulatory blood pressure monitoring

Key Point
Masked hypertension is characterized by a normal office blood pressure measurement and high ambulatory blood pressure measurement

Educational Objective
Diagnose masked hypertension.

The most appropriate next step in management is to obtain 24-hour ambulatory blood pressure monitoring. Masked hypertension is the most likely cause of this patient's unexplained left ventricular hypertrophy. Masked hypertension is characterized by a normal office blood pressure measurement and high ambulatory blood pressure measurement. This condition may affect up to 10 million persons in the United States. Patients with masked hypertension have a definite increased risk for cardiovascular events compared with patients with normal office and ambulatory blood pressure measurements. Suspicion for masked hypertension is usually raised when the physician is informed of discrepancies between office and home blood pressure readings or the discovery of unexplained findings such as left ventricular hypertrophy. Ambulatory blood pressure monitoring can be used to confirm this diagnosis.

If a diagnosis of hypertrophic cardiomyopathy is suspected despite nondiagnostic echocardiography, cardiac MRI can detect focal areas of ventricular hypertrophy and small areas of scarring, which would support the diagnosis. Echocardiographic findings of hypertrophic cardiomyopathy include asymmetric hypertrophy of the ventricle with preserved systolic function but abnormal diastolic function. This patient's echocardiographic findings are not compatible with hypertrophic cardiomyopathy, and cardiac MRI is not indicated.

There are no clinical trials addressing treatment of masked hypertension. However, treatment is indicated for patients with an elevated average 24-hour ambulatory blood pressure measurement. Initiation of chlorthalidone may be appropriate if masked hypertension is diagnosed with 24-hour ambulatory blood pressure measurement.

The coronary artery calcium (CAC) score correlates with cardiovascular risk but is not a direct measure of the severity of luminal coronary disease, and CAC scores are not indicated for routine screening. CAC measurement may be considered in asymptomatic patients with an intermediate risk of coronary artery disease (10%-20% 10-year risk) because a high CAC score (>400) is an indication for more intensive preventive medical treatment. This patient has no indication for CAC scoring, and it cannot explain the patient's left ventricular hypertrophy.

Cuspidi C, Negri F, Sala C, Mancia G. Masked hypertension and echocardiographic left ventricular hypertrophy: an updated overview. Blood Press Monit. 2012;17(1):8-13. PMID: 22183044

Question 2

An 81-year-old woman is evaluated during a follow-up visit for a 3-year history of hypertension. She feels relatively well. She does not smoke cigarettes. She appears to be adherent to her medication regimen, which consists of maximum doses of chlorthalidone, enalapril, amlodipine, and carvedilol.

On physical examination, seated blood pressure is 158/68 mm Hg, and pulse rate is 68/min; other vital signs are normal. BMI is 26. An unchanged systolic crescendo-decrescendo murmur is noted at the right upper sternal border. The carotid upstrokes are normal, and no bruits are heard. Trace pedal edema is noted.

Laboratory studies reveal normal electrolytes, complete blood count, fasting glucose, and fasting lipid profile as well as normal kidney function.

Which of the following is the most appropriate next step in management of this patient's blood pressure?

A. Ambulatory blood pressure monitoring
B. Echocardiography
C. Hydralazine
D. Urine metanephrine measurement

Correct Answer
A. Ambulatory blood pressure monitoring

Key Point
Resistant hypertension is defined as blood pressure that remains above goal despite treatment with the optimal dosages of three antihypertensive agents of different classes, including a diuretic.

Educational Objective
Diagnose resistant hypertension.

Ambulatory blood pressure monitoring is the most appropriate next step in management. This patient meets the diagnostic criteria for resistant hypertension, which is defined as blood pressure that remains above goal despite treatment with the optimal dosages of three antihypertensive agents of different classes, including a diuretic. Patient characteristics more likely to be associated with resistant hypertension include older age, BMI greater than 30, higher baseline blood pressure, diabetes mellitus, and black race. However, before this diagnosis is made, it is necessary to establish that this patient's blood pressure is truly high outside of the office. Ambulatory blood pressure monitoring can differentiate true resistant hypertension from a white coat effect that misleadingly suggests resistance to therapy. Once resistant hypertension is verified, a search for identifiable factors that may be modified is appropriate, including high salt intake, concurrent use of drugs such as NSAIDs, and the presence of other potentially exacerbating medical conditions such as obstructive sleep apnea.

Although potentially useful in assessing this patient's murmur or other suspected structural heart disease, echocardiography is not specifically indicated for evaluation of her hypertension.

The addition of another antihypertensive agent may be required for adequate blood pressure control but should be initiated only after resistant hypertension is diagnosed and other complicating factors are excluded.

In patients with resistant hypertension, consideration of possible secondary causes, such as assessment for catecholamine excess, may be indicated, but only after documentation that the diagnosis of resistant hypertension has been confirmed.

Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension. 2008;51(6):1403-1419. PMID: 18391085

These questions were derived from MKSAP® 16, 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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