Lucy Witt MD, MPH

Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.

Study design: A multicenter, prospective, randomized, double-blind study.

Setting: ICUs in nine French hospitals.

Synopsis: Adults (older than 18 years old) who suffered cardiogenic shock following successful revascularization after AMI were enrolled. Fifty-seven patients were randomly assigned to receive either norepinephrine or epinephrine with patients, nurses, and physicians unaware of which study drug was being used. The primary outcome variable was change in cardiac index within the first 72 hours, and refractory cardiogenic shock served as the main safety endpoint. This study was stopped early because of the higher risk of refractory cardiogenic shock noted in the epinephrine group, compared with that seen in the norepinephrine group (10 of 27 vs. 2 of 30; P = .011). There was no difference in evolution of cardiac index (P = .43) between the two groups. Potentially harmful metabolic and physiologic changes were noted in the epinephrine group including greater lactic acidosis and increased heart rate.

This study was underpowered for clinical endpoints because of the study’s early termination. It also did not include patients in cardiogenic shock from other causes, such as myositis or postcardiopulmonary bypass.

Bottom line: For patients in cardiogenic shock after AMI with successful reperfusion, epinephrine use was associated with increased refractory cardiogenic shock, compared with norepinephrine use.

Citation: Levy B et al. Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-82.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.

Study design: A multicenter, prospective, randomized, double-blind study.

Setting: ICUs in nine French hospitals.

Synopsis: Adults (older than 18 years old) who suffered cardiogenic shock following successful revascularization after AMI were enrolled. Fifty-seven patients were randomly assigned to receive either norepinephrine or epinephrine with patients, nurses, and physicians unaware of which study drug was being used. The primary outcome variable was change in cardiac index within the first 72 hours, and refractory cardiogenic shock served as the main safety endpoint. This study was stopped early because of the higher risk of refractory cardiogenic shock noted in the epinephrine group, compared with that seen in the norepinephrine group (10 of 27 vs. 2 of 30; P = .011). There was no difference in evolution of cardiac index (P = .43) between the two groups. Potentially harmful metabolic and physiologic changes were noted in the epinephrine group including greater lactic acidosis and increased heart rate.

This study was underpowered for clinical endpoints because of the study’s early termination. It also did not include patients in cardiogenic shock from other causes, such as myositis or postcardiopulmonary bypass.

Bottom line: For patients in cardiogenic shock after AMI with successful reperfusion, epinephrine use was associated with increased refractory cardiogenic shock, compared with norepinephrine use.

Citation: Levy B et al. Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-82.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.

Study design: A multicenter, prospective, randomized, double-blind study.

Setting: ICUs in nine French hospitals.

Synopsis: Adults (older than 18 years old) who suffered cardiogenic shock following successful revascularization after AMI were enrolled. Fifty-seven patients were randomly assigned to receive either norepinephrine or epinephrine with patients, nurses, and physicians unaware of which study drug was being used. The primary outcome variable was change in cardiac index within the first 72 hours, and refractory cardiogenic shock served as the main safety endpoint. This study was stopped early because of the higher risk of refractory cardiogenic shock noted in the epinephrine group, compared with that seen in the norepinephrine group (10 of 27 vs. 2 of 30; P = .011). There was no difference in evolution of cardiac index (P = .43) between the two groups. Potentially harmful metabolic and physiologic changes were noted in the epinephrine group including greater lactic acidosis and increased heart rate.

This study was underpowered for clinical endpoints because of the study’s early termination. It also did not include patients in cardiogenic shock from other causes, such as myositis or postcardiopulmonary bypass.

Bottom line: For patients in cardiogenic shock after AMI with successful reperfusion, epinephrine use was associated with increased refractory cardiogenic shock, compared with norepinephrine use.

Citation: Levy B et al. Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-82.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: As frequency of imaging studies increases, and those studies become more advanced, incidental findings on imaging are a growing concern. Incidentalomas can lead to anxiety for patients, increased testing, and possible interventions such as biopsies. Current literature does not provide adequate guidance for providers to discuss the risks of incidentalomas with patients, nor are there clear methods described to manage incidentalomas when discovered.

Study design: This study was an umbrella review of systematic reviews and meta-analyses. Authors conduced their own meta-analyses using data from pooled sources.

Setting: MEDLINE and EMBASE were searched, which resulted in 20 unique systematic reviews analyzed, 15 of which provided incidence data and 18 included outcome data.

Synopsis: To assess prevalence of incidentalomas, the authors conducted nine meta-analyses, with a median number of 14,409 patients. Each analysis was created based on the imaging modality used and the area of the body where the incidental finding occurred. They examined the outcomes specific to incidentalomas within those organs. Their analysis showed that CT of the chest had the highest prevalence of incidentalomas (45%; 95% confidence interval, 36%-55%). Incidental findings in the breast had the highest rates of malignancy (42%; 95% CI, 31%-54%). Noncancerous outcomes described included disc degeneration on MRIs of the spine, aneurysms in brain imaging, and subclinical Cushing’s syndrome. There was significant heterogeneity in all the meta-analyses conducted.

Limitations included variations in how primary study authors defined a positive result and in imaging protocols. Although the authors of this study used primary data extracted from the individual studies in the systematic reviews, they did not analyze the primary studies for inclusion based on methods.

Bottom line: This study provides guidance to clinicians regarding counseling patients on the risks of incidentalomas and how to manage those incidental findings.

Citation: O’Sullivan JW et al. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ. 2018 Jun 18. doi: 10.1136/bmj.k2387.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: As frequency of imaging studies increases, and those studies become more advanced, incidental findings on imaging are a growing concern. Incidentalomas can lead to anxiety for patients, increased testing, and possible interventions such as biopsies. Current literature does not provide adequate guidance for providers to discuss the risks of incidentalomas with patients, nor are there clear methods described to manage incidentalomas when discovered.

Study design: This study was an umbrella review of systematic reviews and meta-analyses. Authors conduced their own meta-analyses using data from pooled sources.

Setting: MEDLINE and EMBASE were searched, which resulted in 20 unique systematic reviews analyzed, 15 of which provided incidence data and 18 included outcome data.

Synopsis: To assess prevalence of incidentalomas, the authors conducted nine meta-analyses, with a median number of 14,409 patients. Each analysis was created based on the imaging modality used and the area of the body where the incidental finding occurred. They examined the outcomes specific to incidentalomas within those organs. Their analysis showed that CT of the chest had the highest prevalence of incidentalomas (45%; 95% confidence interval, 36%-55%). Incidental findings in the breast had the highest rates of malignancy (42%; 95% CI, 31%-54%). Noncancerous outcomes described included disc degeneration on MRIs of the spine, aneurysms in brain imaging, and subclinical Cushing’s syndrome. There was significant heterogeneity in all the meta-analyses conducted.

Limitations included variations in how primary study authors defined a positive result and in imaging protocols. Although the authors of this study used primary data extracted from the individual studies in the systematic reviews, they did not analyze the primary studies for inclusion based on methods.

Bottom line: This study provides guidance to clinicians regarding counseling patients on the risks of incidentalomas and how to manage those incidental findings.

Citation: O’Sullivan JW et al. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ. 2018 Jun 18. doi: 10.1136/bmj.k2387.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: As frequency of imaging studies increases, and those studies become more advanced, incidental findings on imaging are a growing concern. Incidentalomas can lead to anxiety for patients, increased testing, and possible interventions such as biopsies. Current literature does not provide adequate guidance for providers to discuss the risks of incidentalomas with patients, nor are there clear methods described to manage incidentalomas when discovered.

Study design: This study was an umbrella review of systematic reviews and meta-analyses. Authors conduced their own meta-analyses using data from pooled sources.

Setting: MEDLINE and EMBASE were searched, which resulted in 20 unique systematic reviews analyzed, 15 of which provided incidence data and 18 included outcome data.

Synopsis: To assess prevalence of incidentalomas, the authors conducted nine meta-analyses, with a median number of 14,409 patients. Each analysis was created based on the imaging modality used and the area of the body where the incidental finding occurred. They examined the outcomes specific to incidentalomas within those organs. Their analysis showed that CT of the chest had the highest prevalence of incidentalomas (45%; 95% confidence interval, 36%-55%). Incidental findings in the breast had the highest rates of malignancy (42%; 95% CI, 31%-54%). Noncancerous outcomes described included disc degeneration on MRIs of the spine, aneurysms in brain imaging, and subclinical Cushing’s syndrome. There was significant heterogeneity in all the meta-analyses conducted.

Limitations included variations in how primary study authors defined a positive result and in imaging protocols. Although the authors of this study used primary data extracted from the individual studies in the systematic reviews, they did not analyze the primary studies for inclusion based on methods.

Bottom line: This study provides guidance to clinicians regarding counseling patients on the risks of incidentalomas and how to manage those incidental findings.

Citation: O’Sullivan JW et al. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ. 2018 Jun 18. doi: 10.1136/bmj.k2387.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.