We discussed a case of a middle aged woman who presented with subacute to acute shortness of breath on exertion. We discussed her EKG with S1Q3T3 findings which is not specific for PE but indicative of cor-pulmonale. The differential for cor-pulmonale is COPD, ARDS, PNA, Pneumothorax and PE. More specifically, her CTA showed bilateral pulmonary embolus and RV enlargement and her labs indicated elevation in BNP and troponin. Due to her hemodynamic stability but clear evidence of RV strain, troponin and BNP elevation – she was classified as submassive PE (these days known as intermediate high risk classification). In addition to starting heparin infusion, with all submassive PE, it is important to consider systemic thrombolysis (low dose vs high dose) AND catheter directed thrombolysis / thrombectomy. This will be a nuanced discussion but admission to ICU and early consults to IR, Cardiology and Pulmonology are required.
Quick rundown of the articles we talked about today in morning report:
- ANDROMEDA-SHOCK trial, JAMA 2019: RCT of 424 patients with septic shock randomized to capillary refill vs lactate to target resuscitation efforts. Primary outcome of interest was 28 day mortality. While the difference between the two groups was not statistically significant, the study may have been underpowered. Interestingly, there were lower rates of organ dysfunction at 72 hours with the cap refill guided resuscitation than lactate. So keep doing your cap refill bedside exam!
- E-cigarettes vs nicotine-replacement therapy (NRT): Multi-center RCT in the UK that randomized 886 people to e-cigarettes or NRT of their choice for 3 months. Outcome of interest was abstinence from smoking at 6 months and 1 year. They found a significantly higher rate of abstinence in the e-cigarette group than the NRT group. However, while only 9% of the abstinent NRT users were still using NRTs at 1 year, over 80% of the abstinent e-cigarette users were still using e-cigarettes at the end of the study period! Together with the alarmingly high incidence of e-cigarette use amongst adolescents, the results of this study would have to be interpreted cautiously.
- EAGLES trial. Lancet. 2016: Multi-center, double-blind, RCT looking at neuropsychiatric effects of varenicline (Chantix), bupropion, or nicotine patch or placebo involving ~4k people without psych history and 4k people with psychiatric history. Study found that Chantix resulted in the highest rates of sustained abstinence across all study arms. In the psychiatric cohort, there were no differences between the treatment groups in terms of rates of psychiatric events. Bottom line: use Chantix whenever you can to help your patients trying to quit smoking!
- EXTEND trial. NEJM. 2019: Multi-center, randomized, placebo-controlled trial of 225 patients who presented with ischemic stroke within 4.5-9 hours after onset of symptoms with radiologic evidence of salvageable brain tissue randomized to receive tPA vs conservative management. The primary outcome of interest was functional status at 90 days and was significantly better for the intervention group vs control arm. Caveats are that symptomatic intracranial hemorrhage was six times higher in the intervention group than the control arm. 65% of the patients in the study woke up with neurologic deficits and had an unknown time of onset.
- Thyroid hormone replacement for subclinical hypothyroidism (Feller et al. JAMA. 2018): Meta-analysis of 21 RCTs with 2192 patients randomized to hormone replacement or no replacement. The study found no significant difference in qualify of life, thyroid replacement symptoms, fatigure/tiredness, depression, cognition, or SBP after 12 months of therapy. Based on this study, the new guidelines state that in patients with no symptoms of hypothyroidism or non-specific symptoms of hypothyroidism who have fT4 within normal limits and TSH <20, thyroid hormone therapy is strongly recommended against.