User login
Subsegmental PEs overtreated despite link with patient harm
Background: CT pulmonary angiography (CTPA) often detects distal, subsegmental pulmonary embolisms (SSPE) for which there is unclear clinical significance. For these isolated SSPEs, the 2016 CHEST guidelines recommend clinical surveillance in lieu of treatment. Such clinical surveillance has not been associated with an increased recurrence of venous thromboembolism (VTE) over 3 months.
Study design: Retrospective review.
Setting: Tertiary care center in Quebec.
Synopsis: A review of all CTPAs at McGill University in Montreal, from 2014-2016 yielded 222 acute pulmonary emboli (PEs), 71 of which were SSPEs without associated Doppler imaging positive for deep vein thrombosis. Of those 71, 62 (87%) were systemically anticoagulated, compared with 135/143 (94%) of the more proximal PEs. The adverse events of both groups of anticoagulated patients were common and similar. Over the following 3 months, 26 patients in the SSPE group visited the ED or were readmitted (42%; 95% confidence interval, 30%-55%), 21 had a drop in hemoglobin level of 2 g/dL or greater and/or received a blood transfusion (34%; 95% CI, 22%-47%), and 10 died from causes unrelated to VTE (16%; 95% CI, 8%-28%). Limitations of this study included the small number of participants and short time to follow-up.
Bottom line: Although SSPEs have unknown clinical significance, they are being treated with systemic anticoagulation at a similar rate to more proximal PEs and are associated with patient harm.
Citation: Raslan IA et al. Rates of overtreatment and treatment-related adverse effects among patients with subsegmental pulmonary embolism. JAMA Intern Med. 2018 Sep 1;178(9):1272-4.
Dr. Shaw is an assistant professor in the division of hospital medicine, University of New Mexico.
Background: CT pulmonary angiography (CTPA) often detects distal, subsegmental pulmonary embolisms (SSPE) for which there is unclear clinical significance. For these isolated SSPEs, the 2016 CHEST guidelines recommend clinical surveillance in lieu of treatment. Such clinical surveillance has not been associated with an increased recurrence of venous thromboembolism (VTE) over 3 months.
Study design: Retrospective review.
Setting: Tertiary care center in Quebec.
Synopsis: A review of all CTPAs at McGill University in Montreal, from 2014-2016 yielded 222 acute pulmonary emboli (PEs), 71 of which were SSPEs without associated Doppler imaging positive for deep vein thrombosis. Of those 71, 62 (87%) were systemically anticoagulated, compared with 135/143 (94%) of the more proximal PEs. The adverse events of both groups of anticoagulated patients were common and similar. Over the following 3 months, 26 patients in the SSPE group visited the ED or were readmitted (42%; 95% confidence interval, 30%-55%), 21 had a drop in hemoglobin level of 2 g/dL or greater and/or received a blood transfusion (34%; 95% CI, 22%-47%), and 10 died from causes unrelated to VTE (16%; 95% CI, 8%-28%). Limitations of this study included the small number of participants and short time to follow-up.
Bottom line: Although SSPEs have unknown clinical significance, they are being treated with systemic anticoagulation at a similar rate to more proximal PEs and are associated with patient harm.
Citation: Raslan IA et al. Rates of overtreatment and treatment-related adverse effects among patients with subsegmental pulmonary embolism. JAMA Intern Med. 2018 Sep 1;178(9):1272-4.
Dr. Shaw is an assistant professor in the division of hospital medicine, University of New Mexico.
Background: CT pulmonary angiography (CTPA) often detects distal, subsegmental pulmonary embolisms (SSPE) for which there is unclear clinical significance. For these isolated SSPEs, the 2016 CHEST guidelines recommend clinical surveillance in lieu of treatment. Such clinical surveillance has not been associated with an increased recurrence of venous thromboembolism (VTE) over 3 months.
Study design: Retrospective review.
Setting: Tertiary care center in Quebec.
Synopsis: A review of all CTPAs at McGill University in Montreal, from 2014-2016 yielded 222 acute pulmonary emboli (PEs), 71 of which were SSPEs without associated Doppler imaging positive for deep vein thrombosis. Of those 71, 62 (87%) were systemically anticoagulated, compared with 135/143 (94%) of the more proximal PEs. The adverse events of both groups of anticoagulated patients were common and similar. Over the following 3 months, 26 patients in the SSPE group visited the ED or were readmitted (42%; 95% confidence interval, 30%-55%), 21 had a drop in hemoglobin level of 2 g/dL or greater and/or received a blood transfusion (34%; 95% CI, 22%-47%), and 10 died from causes unrelated to VTE (16%; 95% CI, 8%-28%). Limitations of this study included the small number of participants and short time to follow-up.
Bottom line: Although SSPEs have unknown clinical significance, they are being treated with systemic anticoagulation at a similar rate to more proximal PEs and are associated with patient harm.
Citation: Raslan IA et al. Rates of overtreatment and treatment-related adverse effects among patients with subsegmental pulmonary embolism. JAMA Intern Med. 2018 Sep 1;178(9):1272-4.
Dr. Shaw is an assistant professor in the division of hospital medicine, University of New Mexico.
Restrictive transfusion strategy in cardiac surgery remains noninferior
Clinical question: Does using a restrictive transfusion strategy with patients undergoing cardiac surgery affect long-term outcomes?
Background: Using a restrictive transfusion strategy in patients undergoing cardiac surgery is known to use fewer units of allogeneic red cells, compared with a liberal strategy, while still having noninferior short-term clinical outcomes. At this time, little is known about such a strategy’s long-term effects.
Study design: Randomized, open-label, noninferiority trial.
Setting: 74 hospitals in 19 countries.
Synopsis: 5,243 adults undergoing nontransplant cardiac surgeries and having at least a moderate predicted risk for death were randomly divided into a liberal or restrictive transfusion strategy. Restrictive-strategy participants received a transfusion when hemoglobin was less than 7.5 g/dL, compared with either a hemoglobin of 8.5 g/dL on the floor or 9.5 g/dL in the ICU for the liberal-strategy group. During the hospitalization, the restrictive group received fewer U of red cells and had a lower mean predischarge hemoglobin. At 6 months, the groups were compared for the primary outcomes of death, MI, stroke, or renal failure requiring dialysis, finding an occurrence of such in 402/2,317 in the restrictive-strategy group and 402/2,347 in the liberal-strategy group (P = .006 for noninferiority). Limitations include the study being a noninferiority trial and the very specific patient population selected.
Bottom line: In patients undergoing cardiac surgery, a restrictive transfusion strategy is noninferior to a liberal strategy with respect to death from any cause, MI, stroke, and new renal failure requiring dialysis at 6 months postop.
Citation: Mazer CD et al. Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Eng J Med. 2018 Sep 27;379(13):1224-33.
Dr. Shaw is an assistant professor in the division of hospital medicine,University of New Mexico.
Clinical question: Does using a restrictive transfusion strategy with patients undergoing cardiac surgery affect long-term outcomes?
Background: Using a restrictive transfusion strategy in patients undergoing cardiac surgery is known to use fewer units of allogeneic red cells, compared with a liberal strategy, while still having noninferior short-term clinical outcomes. At this time, little is known about such a strategy’s long-term effects.
Study design: Randomized, open-label, noninferiority trial.
Setting: 74 hospitals in 19 countries.
Synopsis: 5,243 adults undergoing nontransplant cardiac surgeries and having at least a moderate predicted risk for death were randomly divided into a liberal or restrictive transfusion strategy. Restrictive-strategy participants received a transfusion when hemoglobin was less than 7.5 g/dL, compared with either a hemoglobin of 8.5 g/dL on the floor or 9.5 g/dL in the ICU for the liberal-strategy group. During the hospitalization, the restrictive group received fewer U of red cells and had a lower mean predischarge hemoglobin. At 6 months, the groups were compared for the primary outcomes of death, MI, stroke, or renal failure requiring dialysis, finding an occurrence of such in 402/2,317 in the restrictive-strategy group and 402/2,347 in the liberal-strategy group (P = .006 for noninferiority). Limitations include the study being a noninferiority trial and the very specific patient population selected.
Bottom line: In patients undergoing cardiac surgery, a restrictive transfusion strategy is noninferior to a liberal strategy with respect to death from any cause, MI, stroke, and new renal failure requiring dialysis at 6 months postop.
Citation: Mazer CD et al. Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Eng J Med. 2018 Sep 27;379(13):1224-33.
Dr. Shaw is an assistant professor in the division of hospital medicine,University of New Mexico.
Clinical question: Does using a restrictive transfusion strategy with patients undergoing cardiac surgery affect long-term outcomes?
Background: Using a restrictive transfusion strategy in patients undergoing cardiac surgery is known to use fewer units of allogeneic red cells, compared with a liberal strategy, while still having noninferior short-term clinical outcomes. At this time, little is known about such a strategy’s long-term effects.
Study design: Randomized, open-label, noninferiority trial.
Setting: 74 hospitals in 19 countries.
Synopsis: 5,243 adults undergoing nontransplant cardiac surgeries and having at least a moderate predicted risk for death were randomly divided into a liberal or restrictive transfusion strategy. Restrictive-strategy participants received a transfusion when hemoglobin was less than 7.5 g/dL, compared with either a hemoglobin of 8.5 g/dL on the floor or 9.5 g/dL in the ICU for the liberal-strategy group. During the hospitalization, the restrictive group received fewer U of red cells and had a lower mean predischarge hemoglobin. At 6 months, the groups were compared for the primary outcomes of death, MI, stroke, or renal failure requiring dialysis, finding an occurrence of such in 402/2,317 in the restrictive-strategy group and 402/2,347 in the liberal-strategy group (P = .006 for noninferiority). Limitations include the study being a noninferiority trial and the very specific patient population selected.
Bottom line: In patients undergoing cardiac surgery, a restrictive transfusion strategy is noninferior to a liberal strategy with respect to death from any cause, MI, stroke, and new renal failure requiring dialysis at 6 months postop.
Citation: Mazer CD et al. Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Eng J Med. 2018 Sep 27;379(13):1224-33.
Dr. Shaw is an assistant professor in the division of hospital medicine,University of New Mexico.