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Risk stratification of syncope patients can help determine duration of telemetry monitoring
Background: About half of ED patients with syncope of unknown etiology are admitted for telemetry monitoring. No consensus exists regarding the optimal duration of telemetry monitoring in these patients to detect underlying arrhythmia.
Study design: Prospective cohort study.
Setting: Six EDs in Canada during September 2010–March 2015.
Synopsis: Using the Canadian Syncope Risk Score, 5,581 adults who presented to the ED within 24 hours of a syncopal event were risk stratified as low, medium, or high risk for serious adverse events (arrhythmic vs. nonarrhythmic) and then followed for 30 days. Approximately half of arrhythmias were identified among low-risk patients within 2 hours of telemetry monitoring and within 6 hours of monitoring among medium- and high-risk patients. In the low-risk group, none experienced death or ventricular arrhythmia within 30 days. In the medium- and high-risk group, 91.7% of underlying arrhythmias were identified within 15 days. The study was limited by the lack of standardized approach in the use of outpatient cardiac rhythm monitoring, which may have resulted in arrhythmia underdetection.
Bottom line: Among ED patients with syncope of unknown etiology, approximately 47% of arrhythmias were detected after 2-6 hours of telemetry monitoring. Among medium- and high-risk patients, the majority of serious arrhythmias were identified within 15 days. Based on these results, the authors recommend the use of 15-day outpatient cardiac monitoring for medium- and high-risk patients.
Citation: Thiruganasambandamoorthy V et al. Duration of electrocardiographic monitoring of emergency department patients with syncope. Circulation. 2019 Mar 12;139(11):1396-406.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.
Background: About half of ED patients with syncope of unknown etiology are admitted for telemetry monitoring. No consensus exists regarding the optimal duration of telemetry monitoring in these patients to detect underlying arrhythmia.
Study design: Prospective cohort study.
Setting: Six EDs in Canada during September 2010–March 2015.
Synopsis: Using the Canadian Syncope Risk Score, 5,581 adults who presented to the ED within 24 hours of a syncopal event were risk stratified as low, medium, or high risk for serious adverse events (arrhythmic vs. nonarrhythmic) and then followed for 30 days. Approximately half of arrhythmias were identified among low-risk patients within 2 hours of telemetry monitoring and within 6 hours of monitoring among medium- and high-risk patients. In the low-risk group, none experienced death or ventricular arrhythmia within 30 days. In the medium- and high-risk group, 91.7% of underlying arrhythmias were identified within 15 days. The study was limited by the lack of standardized approach in the use of outpatient cardiac rhythm monitoring, which may have resulted in arrhythmia underdetection.
Bottom line: Among ED patients with syncope of unknown etiology, approximately 47% of arrhythmias were detected after 2-6 hours of telemetry monitoring. Among medium- and high-risk patients, the majority of serious arrhythmias were identified within 15 days. Based on these results, the authors recommend the use of 15-day outpatient cardiac monitoring for medium- and high-risk patients.
Citation: Thiruganasambandamoorthy V et al. Duration of electrocardiographic monitoring of emergency department patients with syncope. Circulation. 2019 Mar 12;139(11):1396-406.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.
Background: About half of ED patients with syncope of unknown etiology are admitted for telemetry monitoring. No consensus exists regarding the optimal duration of telemetry monitoring in these patients to detect underlying arrhythmia.
Study design: Prospective cohort study.
Setting: Six EDs in Canada during September 2010–March 2015.
Synopsis: Using the Canadian Syncope Risk Score, 5,581 adults who presented to the ED within 24 hours of a syncopal event were risk stratified as low, medium, or high risk for serious adverse events (arrhythmic vs. nonarrhythmic) and then followed for 30 days. Approximately half of arrhythmias were identified among low-risk patients within 2 hours of telemetry monitoring and within 6 hours of monitoring among medium- and high-risk patients. In the low-risk group, none experienced death or ventricular arrhythmia within 30 days. In the medium- and high-risk group, 91.7% of underlying arrhythmias were identified within 15 days. The study was limited by the lack of standardized approach in the use of outpatient cardiac rhythm monitoring, which may have resulted in arrhythmia underdetection.
Bottom line: Among ED patients with syncope of unknown etiology, approximately 47% of arrhythmias were detected after 2-6 hours of telemetry monitoring. Among medium- and high-risk patients, the majority of serious arrhythmias were identified within 15 days. Based on these results, the authors recommend the use of 15-day outpatient cardiac monitoring for medium- and high-risk patients.
Citation: Thiruganasambandamoorthy V et al. Duration of electrocardiographic monitoring of emergency department patients with syncope. Circulation. 2019 Mar 12;139(11):1396-406.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.
Oral vs. IV antibiotic therapy in early treatment of complex bone and joint infections
Background: The standard of care for complex bone and joint infections includes the use of IV antibiotics. A prior meta-analysis suggested that the outcomes for bone and joint infections treated with oral and IV antibiotics are similar.
Study design: Randomized, controlled trial.
Setting: Twenty-six U.K. sites during June 2010–October 2015.
Synopsis: The study enrolled 1,054 adults with bone or joint infections who would have been treated with 6 weeks of IV antibiotics; they were then randomized to receive either IV or oral antibiotics. Treatment regimens were selected by infectious disease specialists. The rate of the primary endpoint, definite treatment failure at 1 year after randomization, was 14.6% in the intravenous group and 13.2% in the oral group. The difference in the risk of definite treatment failure between the two groups was –1.4% (95% confidence interval, –5.6 to 2.9), which met the predefined noninferiority criteria. The use of oral antibiotics also was associated with a shorter hospital stay and fewer complications. The conclusions of the trial are limited by the open-label design. An associated editorial advocated for additional research before widespread change to current treatment recommendations.
Bottom line: Bone and joint infections treated with oral versus IV antibiotics may have similar treatment failure rates.
Citation: Li HK et al. Oral versus intravenous antibiotics for bone and joint infection. N Eng J Med. 2019 Jan 31;380(5):425-36.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.
Background: The standard of care for complex bone and joint infections includes the use of IV antibiotics. A prior meta-analysis suggested that the outcomes for bone and joint infections treated with oral and IV antibiotics are similar.
Study design: Randomized, controlled trial.
Setting: Twenty-six U.K. sites during June 2010–October 2015.
Synopsis: The study enrolled 1,054 adults with bone or joint infections who would have been treated with 6 weeks of IV antibiotics; they were then randomized to receive either IV or oral antibiotics. Treatment regimens were selected by infectious disease specialists. The rate of the primary endpoint, definite treatment failure at 1 year after randomization, was 14.6% in the intravenous group and 13.2% in the oral group. The difference in the risk of definite treatment failure between the two groups was –1.4% (95% confidence interval, –5.6 to 2.9), which met the predefined noninferiority criteria. The use of oral antibiotics also was associated with a shorter hospital stay and fewer complications. The conclusions of the trial are limited by the open-label design. An associated editorial advocated for additional research before widespread change to current treatment recommendations.
Bottom line: Bone and joint infections treated with oral versus IV antibiotics may have similar treatment failure rates.
Citation: Li HK et al. Oral versus intravenous antibiotics for bone and joint infection. N Eng J Med. 2019 Jan 31;380(5):425-36.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.
Background: The standard of care for complex bone and joint infections includes the use of IV antibiotics. A prior meta-analysis suggested that the outcomes for bone and joint infections treated with oral and IV antibiotics are similar.
Study design: Randomized, controlled trial.
Setting: Twenty-six U.K. sites during June 2010–October 2015.
Synopsis: The study enrolled 1,054 adults with bone or joint infections who would have been treated with 6 weeks of IV antibiotics; they were then randomized to receive either IV or oral antibiotics. Treatment regimens were selected by infectious disease specialists. The rate of the primary endpoint, definite treatment failure at 1 year after randomization, was 14.6% in the intravenous group and 13.2% in the oral group. The difference in the risk of definite treatment failure between the two groups was –1.4% (95% confidence interval, –5.6 to 2.9), which met the predefined noninferiority criteria. The use of oral antibiotics also was associated with a shorter hospital stay and fewer complications. The conclusions of the trial are limited by the open-label design. An associated editorial advocated for additional research before widespread change to current treatment recommendations.
Bottom line: Bone and joint infections treated with oral versus IV antibiotics may have similar treatment failure rates.
Citation: Li HK et al. Oral versus intravenous antibiotics for bone and joint infection. N Eng J Med. 2019 Jan 31;380(5):425-36.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.
Patent foramen ovale may be associated with increased risk of perioperative ischemic stroke
Clinical question: Are patients with patent foramen ovale (PFO) at increased risk of perioperative ischemic stroke?
Background: Prior research has identified an association between PFO and risk of stroke. However, little is known about the effect of a preoperatively diagnosed PFO on perioperative stroke risk.
Study design: Retrospective cohort study.
Setting: Three Massachusetts hospitals, from January 2007 to December 2015.
Synopsis: The charts of 150,198 adult patients who underwent noncardiac surgery were reviewed for ICD codes for PFO. The primary outcome was perioperative ischemic stroke within 30 days of surgery, as identified via ICD code and subsequent chart review. After they adjusted for confounding variables, the study authors found that patients with PFO had an increased risk of perioperative ischemic stroke (odds ratio, 2.66; 95% confidence interval, 1.96-3.63; P less than .001) compared with patients without PFO. These findings were replicated in a propensity score–matched cohort to adjust for baseline differences between PFO and non-PFO groups. Patients with PFO also had a significantly increased risk of large-vessel territory ischemia and more severe neurologic deficits.
Given the observational design, this study could not establish a causal relationship between presence of a PFO and perioperative stroke. While the results support the consideration of PFO as a risk factor for perioperative stroke, research into whether this risk can be mitigated is needed.
Bottom line: Patients with PFO undergoing noncardiac surgery may be at increased risk of perioperative ischemic stroke.
Citation: Ng PY et al. Association of preoperatively diagnosed patent foramen ovale with perioperative ischemic stroke. JAMA. 2018 Feb 6;319(5):452-62.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Clinical question: Are patients with patent foramen ovale (PFO) at increased risk of perioperative ischemic stroke?
Background: Prior research has identified an association between PFO and risk of stroke. However, little is known about the effect of a preoperatively diagnosed PFO on perioperative stroke risk.
Study design: Retrospective cohort study.
Setting: Three Massachusetts hospitals, from January 2007 to December 2015.
Synopsis: The charts of 150,198 adult patients who underwent noncardiac surgery were reviewed for ICD codes for PFO. The primary outcome was perioperative ischemic stroke within 30 days of surgery, as identified via ICD code and subsequent chart review. After they adjusted for confounding variables, the study authors found that patients with PFO had an increased risk of perioperative ischemic stroke (odds ratio, 2.66; 95% confidence interval, 1.96-3.63; P less than .001) compared with patients without PFO. These findings were replicated in a propensity score–matched cohort to adjust for baseline differences between PFO and non-PFO groups. Patients with PFO also had a significantly increased risk of large-vessel territory ischemia and more severe neurologic deficits.
Given the observational design, this study could not establish a causal relationship between presence of a PFO and perioperative stroke. While the results support the consideration of PFO as a risk factor for perioperative stroke, research into whether this risk can be mitigated is needed.
Bottom line: Patients with PFO undergoing noncardiac surgery may be at increased risk of perioperative ischemic stroke.
Citation: Ng PY et al. Association of preoperatively diagnosed patent foramen ovale with perioperative ischemic stroke. JAMA. 2018 Feb 6;319(5):452-62.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Clinical question: Are patients with patent foramen ovale (PFO) at increased risk of perioperative ischemic stroke?
Background: Prior research has identified an association between PFO and risk of stroke. However, little is known about the effect of a preoperatively diagnosed PFO on perioperative stroke risk.
Study design: Retrospective cohort study.
Setting: Three Massachusetts hospitals, from January 2007 to December 2015.
Synopsis: The charts of 150,198 adult patients who underwent noncardiac surgery were reviewed for ICD codes for PFO. The primary outcome was perioperative ischemic stroke within 30 days of surgery, as identified via ICD code and subsequent chart review. After they adjusted for confounding variables, the study authors found that patients with PFO had an increased risk of perioperative ischemic stroke (odds ratio, 2.66; 95% confidence interval, 1.96-3.63; P less than .001) compared with patients without PFO. These findings were replicated in a propensity score–matched cohort to adjust for baseline differences between PFO and non-PFO groups. Patients with PFO also had a significantly increased risk of large-vessel territory ischemia and more severe neurologic deficits.
Given the observational design, this study could not establish a causal relationship between presence of a PFO and perioperative stroke. While the results support the consideration of PFO as a risk factor for perioperative stroke, research into whether this risk can be mitigated is needed.
Bottom line: Patients with PFO undergoing noncardiac surgery may be at increased risk of perioperative ischemic stroke.
Citation: Ng PY et al. Association of preoperatively diagnosed patent foramen ovale with perioperative ischemic stroke. JAMA. 2018 Feb 6;319(5):452-62.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
PE is rare in patients presenting to the ED with syncope
Clinical question: What is the prevalence of pulmonary embolism (PE) in patients presenting to the ED with syncope?
Study design: Retrospective, observational study.
Setting: Canada, Denmark, Italy, and the United States, from January 2010 to September 2016.
Synopsis: Longitudinal administrative databases were used to identify patients with ICD codes for syncope at discharge from the ED or hospital. Those with an ICD code for PE were included to calculate the prevalence of PE in this population (primary outcome).
The prevalence of PE in all patients ranged from 0.06% (95% confidence interval, 0.05%-0.06%) to 0.55% (95% CI, 0.50%-0.61%); and in hospitalized patients from 0.15% (95% CI, 0.14%-0.16%) to 2.10% (95% CI, 1.84%-2.39%). This is a much lower than the estimated 17.3% prevalence of PE in patients presenting with syncope estimated by the PESIT study published in the New England Journal of Medicine in 2016. Further definitive research is needed to better characterize prevalence rates.
Limitations of this study include the potential for information bias: The inclusion criteria of patients coded for syncope at discharge likely omits some patients who initially presented with syncope but were coded for a primary diagnosis that caused syncope.
Bottom line: PE in patients presenting to the ED with syncope may be rare.
Citation: Costantino G et al. Prevalence of pulmonary embolism in patients with syncope. JAMA. 2018;178(3):356-62.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Clinical question: What is the prevalence of pulmonary embolism (PE) in patients presenting to the ED with syncope?
Study design: Retrospective, observational study.
Setting: Canada, Denmark, Italy, and the United States, from January 2010 to September 2016.
Synopsis: Longitudinal administrative databases were used to identify patients with ICD codes for syncope at discharge from the ED or hospital. Those with an ICD code for PE were included to calculate the prevalence of PE in this population (primary outcome).
The prevalence of PE in all patients ranged from 0.06% (95% confidence interval, 0.05%-0.06%) to 0.55% (95% CI, 0.50%-0.61%); and in hospitalized patients from 0.15% (95% CI, 0.14%-0.16%) to 2.10% (95% CI, 1.84%-2.39%). This is a much lower than the estimated 17.3% prevalence of PE in patients presenting with syncope estimated by the PESIT study published in the New England Journal of Medicine in 2016. Further definitive research is needed to better characterize prevalence rates.
Limitations of this study include the potential for information bias: The inclusion criteria of patients coded for syncope at discharge likely omits some patients who initially presented with syncope but were coded for a primary diagnosis that caused syncope.
Bottom line: PE in patients presenting to the ED with syncope may be rare.
Citation: Costantino G et al. Prevalence of pulmonary embolism in patients with syncope. JAMA. 2018;178(3):356-62.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Clinical question: What is the prevalence of pulmonary embolism (PE) in patients presenting to the ED with syncope?
Study design: Retrospective, observational study.
Setting: Canada, Denmark, Italy, and the United States, from January 2010 to September 2016.
Synopsis: Longitudinal administrative databases were used to identify patients with ICD codes for syncope at discharge from the ED or hospital. Those with an ICD code for PE were included to calculate the prevalence of PE in this population (primary outcome).
The prevalence of PE in all patients ranged from 0.06% (95% confidence interval, 0.05%-0.06%) to 0.55% (95% CI, 0.50%-0.61%); and in hospitalized patients from 0.15% (95% CI, 0.14%-0.16%) to 2.10% (95% CI, 1.84%-2.39%). This is a much lower than the estimated 17.3% prevalence of PE in patients presenting with syncope estimated by the PESIT study published in the New England Journal of Medicine in 2016. Further definitive research is needed to better characterize prevalence rates.
Limitations of this study include the potential for information bias: The inclusion criteria of patients coded for syncope at discharge likely omits some patients who initially presented with syncope but were coded for a primary diagnosis that caused syncope.
Bottom line: PE in patients presenting to the ED with syncope may be rare.
Citation: Costantino G et al. Prevalence of pulmonary embolism in patients with syncope. JAMA. 2018;178(3):356-62.
Dr. Roy is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.