ACS (Brenner 12/18/2019)

Thank you to Dr. Dan Brenner for his great talk this week on Acute Coronary Syndrome (ACS).

A dear mentor and teacher of mine who knows more than almost anyone I know said in the hallway after GR, “You know, you think you know everything there is to know about a topic, and then you go to Grand Rounds. . .and I learn something new every time!”

It’s true.

Here’s what I learned this week:

·         Family docs are the masters of prevention. (I already knew that!)

o   Diet and exercise modifications can reduce CAD risk up to 50%. Wow!

o   Use the ASVD calculator to guide primary prevention recommendations (not applicable to those with known CAD)

§  Patients with ASCVD 10 year risk >7.5% OR with Diabetes should be on a statin AND aspirin

§  Coronary calcium score may also help guide decisions about ASA for primary prevention

·         Stable Coronary Artery Disease should be managed medically

o   Ischemia Trial  of >5000 patients with stable CAD (excluded left main disease) raises questions about medical management vs. invasive treatment (PCI) in Stable CAD

§  Their bottom line: medical management trumps PCI, BUT I will note that Dr. Brenner took issue with some of their conclusions

·         Optimal medical therapy is CRITICAL in the treatment of stable disease, AND  revascularization may still be indicated in patients to prevent long-term risk of MI and improve symptoms (i.e. angina)

§  Shared decision-making should be employed (my favorite topic!!)

·         To review definitions in ACS

o   Unstable angina: chest pain, no EKG changes, no cardiac enzyme elevation

o   NSTE-ACS: chest pain, +/- EKG changes (e.g. non-specific, ST depressions, T wave inversions, etc), +cardiac enzyme elevation

o   STEMI: chest pain, ST elevation EKG changes, +/- cardiac enzyme elevation

·         The best thing a patient can do if they are having an MI is call 911. The ambulance can expedite an EKG and mobilize cardiology teams at the hospital because “time is myocardium”

o   Goal EMS to drug (heparin) <30 minutes

o   Goal EMS to balloon <90 minutes

o   Symptom onset to reperfusion <120 minutes

·         Pharmacotherapy: beta blocker (slow heart rate), nitrates, ACE-I, statin, dual antiplatelet (ASA+ ticagrelor, ASA+clopidogrel),

o   Goal: optimize balance of myocardial supply/demand

·         Percutaneous intervention (PCI)

o   Goal: open the artery, optimize balance of myocardial supply/demand

o   Radial approach is better than femoral (decreased risk bleeding complications)

o   After a drug eluting stent (DES) is placed, dual antiplatelet therapy (DAPT) should be continued for at least a year (call the cardiologist if you have questions).

o   Complications of PCI occur of 1-2% of patients: bleeding, contrast-induced neophropathy, Acute CVA/embolism, dissection/perforation, MI, emergent CT surgery, death

·         ACS secondary prevention (that is us again!)

o   Smoking cessation

o   Cardiac rehab (supervised exercise program)

o   Diet

o   Medical therapy: ASA +/- p2y12 inhibitor (ticagrelor, clopidogrel), statin, ACE-I (improved survival), aldosterone antagonist (reduced HF and sudden cardiac death), beta blockers (reduced HF, infarct size, arrhythmia, sudden cardiac death)

Racial Disparities in End of Life Care (Robbins 12/11/2019)

Thank you to Dr.  TC Robbins for an incredibly informative presentation on “Racial Disparities in End-of-Life Care” last week. If you missed it, I highly recommend watching it on zoom! Our summary can’t possibly do it justice!

Here are some of the highlights with resources in bold:

•           African American and Hispanic patients are more likely to be hospitalized and receive aggressive care in last 6 months of life, and much less likely to use hospice services or have an Advanced Directive.
•           Why the racial disparities at the end of life? Evidence shows this is due to the cumulative impact of bias, mistrust of providers at the end of life, provider discomfort with non-beneficial treatment, and language barriers. Consider learning more by reading “Reproductive Justice” by Ross and Salinger, and “Medical Apartheid” by Harriet Washington.
•           Dr. Robbins recommends that we keep in the forefront of our minds the cultural context of our patients’ end-of-life decisions, and check our own bias when we care for our patients. We can start by taking the implicit bias test at https://implicit.harvard.edu
•           Dr. Kimberly Curseen from Emory School of Medicine made an interesting recommendation to make a habit of empathy-make it rote-and tells us it will improve the reliability of our care. See her article  "Implicit Bias and Its Impact on Palliative Care"
•           Another great resource is Stanford University’s series on Cross Cultural Medicine at https://geriatrics.stanford.edu/microlectures.html which includes many helpful videos.

Dr. Robbins gave the following summary points to help us improve communication at the end of life:

•        Don’t enter a conversation with a specific agenda

•        Learn about the patient, who they are, what gives their life meaning

•        Involve providers who know the patient best (including their PCP if possible)

•        Be thoughtful about the timing of the conversation

•        Know who is in the room and who makes decisions

•        Conversation may occur over multiple visits. Be patient.

•        Adjust for health literacy

•        Reduce medical jargon

•        Assess understanding: “I’ve said a lot, please tell me what you understand in your own words so I can make sure I’m speaking clearly”

•        If you’re not completely fluent in the patient’s language, use an interpreter for any serious conversation

•        

And as a final point, remember to provide a POLST (in EPIC using the Advanced Care Planning tab) and Advanced Care Planning https://prepareforyourcare.org/advance-directive-library

Influenza (Green 12/4/2019)

Thanks Dr. Gary Green, for an awesome rapid fire tour de force through influenza-- seasonal and otherwise-- its virology, natural history, pharmaceuticals, complications, with a fascinating dip into medical history with a little future-telling. Plus he handed out Kit Kats. Cannot beat it. If you missed it, here’s the video recording: starts about nine minutes in, Gary Green FLU Grand Rounds

Here’s a few things to know:

• Flu is here (we admitted two new influenza cases in the last 48 hours). 
• It’s an early start to the season in California, a mix of Flu A and B (B usually follows A but this year, they are double dating). 
• As of 11/16, there have been 13 deaths in California (all in people over 50).
• And now for a little history:
• The first recognized and recorded influenza pandemic was in 1510
• The 1918 Spanish flu actually started in Fort Riley, Kansas!
• Influenza caused More than 10x fatalities than WWI
• 28% of the US population was affected, 675,000 people died in US
• S/Sx
• Influenza like illness (ILI): notable for its abrupt onset, fever/chills, headache, myalgias and malaise, cough. GI symptoms (nausea, vomiting, diarrhea) and interestingly leg pain (myalgias) fairly common in kiddos
• As you know, flu is spread by sneezing, coughing (droplets can travel 6 feet), even talking (talking droplets are smaller and can hang around longer)
• Incubation period is 1-4 days (usually 2), average length of shedding 4.8 days (but can be shed for up to 19 days in immunosuppressed) 
• Depending on the year, 12,000-56,000 people die each year in the US of flu, 140,000-700,000 are hospitalized
• Most affected by flu are youngest (<1y) AND oldest (>65y) but every year perfectly healthy 30 and 40 year olds also DIE of the flu
• The vector for flu: CHILDREN. Children tend to get less sick, run around and spread it
• High risk conditions for severe influenza: age (<5, >65), pregnancy (up to 2 weeks postpartum), Native Americans and Alaskan natives.
• Also those with underlying medical conditions: asthma, COPD, neurologic disorders, ESRD, HIV, heart disease, cirrhosis, and morbid obesity (to name a few)
• Complications of influenza: 
• Primary viral pneumonia
• Secondary bacterial pneumonia: in one study, 11-35% of laboratory confirmed flu had bacterial co-secondary infection/CAP (strep 35%) staph (28%)
• Myositis, rhabdo (more common in kids)
• Cardiac: known association with acute MI in elderly within 7d of infection
• Aseptic meningitis (common! High fever, headache)
• Seasonal flu vaccine: ranges in effectiveness 10-60%, average about 50% effective
• Vaccination is the only intervention we have that REDUCES mortality (by 36%), also reduces risk of post-flu PNA by 17%, 
• Meds have not been shown to reduce mortality: Neuramidase inhibitor current standard of care with <48 hours of symptoms (oseltamivir 75mg PO BIDx 5 days). Now also zanamavir (inhaled, contraindicated COPD/Asthma) and IV Peramavir (though maybe not as effective as oseltamivir).
• Did you get your flu shot yet?