Chu Review: Landon 2023’s differences in tx & outcomes of MI based on SES

Landon, et al. 2023. Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries. JAMA Cardiology, 329, 13, p 1088-1097.
https://jamanetwork.com/journals/jama/fullarticle/2803045

One Liner: It is of no surprise that lower income patients that low income pts have worse outcomes and worse access to care in many conditions, specifically in this case STEMI and NSTEMI; will not change my practice

Brief Summary:

• Clinical Question: Are patients that are older and low-income, compared to patients that are high-income, having worse outcomes in acute myocardial infarction, as measured by [primary] 30-d and 1-yr mortality and [secondary] rates of hospital length of stay, 30 d readmission, and is there an income disparity in use of cardiac cath, PCI, CABG during initial hospitalization and within 90 d of admission?
• This study looked at a compilation of data from 6 countries (US, Canada, England, Netherlands, Israel, Taiwan) and specifically used STEMI due to internationally agreed diagnostic criteria.
• The pts used zip code income averages as a proxy to define if a pt had High or Low Income and looked at the top 20% as “High” and bottom 20% as “Low” income.
• The primary outcome (30 d and 1 yr mortality) was worse in low income pts.
• The secondary outcomes (revascularization by cath, PCI, CABG; hospital LOS; readmission within 30 d) were also worse in low income pts.
• Some limitations, like lack of race & ethnicity data (which can inform social determinants of health), lack of discharge disposition (i.e. to SNF, home, which insurance can influence), and also readmissions being “defined” by the primary diagnosis listed for readmission (which some hospitals will unethically change to avoid legislative punishments).

Chu Review: Ammirati 2023’s review on dx and tx of acute myocarditis

Ammirati, et al. 2023. Diagnosis and treatment of acute myocarditis: a review. JAMA, 329, 13, p 1098-1113.
https://jamanetwork.com/journals/jama/fullarticle/2803039

One Liner: Myocarditis may have a preceding viral syndrome, can present with a variety of symptoms of cardiac EOD, dysrhythmias, ischemia, but almost half can have a negative troponin; should get NSAID and ASA, cardiac support, and be admitted; will not change my practice

Brief Summary

• Most common precipitating cause of a preceding viral infection, rarely from autoimmunity and even more rarely from chemotherapy immune checkpoint inhibitors.
• Infective causes can also include HIV, Dengue, Chagas, Lyme disease.
• Certain genes can lead to higher risk and poorer outcomes.
• Most pts are younger adults, predominantly men. Most common symptoms are chest pain, dyspnea, and fever. About 3-9% of pts present with fulminant cardiogenic shock.
• Initial evaluation typically sees elevated troponin and inflammatory markers. Sending off serology for other diseases such as HIV and Borrelia may be recommended.
• ECG can show ischemic changes, esp inferior and lateral leads; wide QRS, AV blocks, ventricular dysrhythmias are high risk.
• Echo can show thickened myocardium, effusion.
• Coronary CT occasionally used, but the main definitive diagnostic modalities are Cardiac MRI and Biopsy.
• All pts with myocarditis should be hospitalized. Uncomplicated cases typically can be treated with NSAID and ASA for chest pain. Complicated cases (LV dysfunction, acute heart failure, ventricular dysrhythmia, advanced AV block, cardiogenic shock) go to the ICU and may need antidysrhythmic medications, pacemaker, defib, cardioversion, etc.
• Medical treatments based on etiology and may involve removal of offending agents, antimicrobials, immunosuppression, steroids.
• Mechanical and surgical supports like AICD, aortic balloon pumps, VA-ECMO, LVAD, and cardiac transplants may be needed.
• Factors worsening prognosis include cardiogenic shock, giant cell, QRS > 120 ms on initial ECG, requirement of mechanical supports, ventricular dysrhythmias, myocardial fibrosis, genetic disorders, and etiology from giant cell myocarditis or immune checkpoint inhibitor.
• Many pediatric cases have a viral prodrome, and most common symptoms are fatigue, less frequently GI symptoms, dyspnea, and chest pain. The differential also includes vasculidites (e.g. Kawasaki), MIS-C, others. No high quality evidence for treatment in children, IVIG and steroids frequently used.

Chu Review: Andersen 2021’s vasopressin and methylprednisolone lack of effect on ROSC for in-hospital cardiac arrest

Andersen, et al. 2021. Effect of Vasopressin and Methylprednisolone vs Placebo on Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest A Randomized Clinical Trial. JAMA, 326, 16, p 1586-1594.
https://jamanetwork.com/journals/jama/fullarticle/2784625

One Liner: A multicenter placebo controlled RCT in Denmark showed very small statistically significant increase in ROSC in adults w cardiac arrest who received vasopressin + methylprednisolone + standard cardiac arrest care, as opposed to placebo + standard cardiac arrest care; this will not change my practice.

Brief Summary:

• About 500 pts who had an in-hospital cardiac arrest were randomized to either receive standard “placebo” cardiac arrest management (namely epinephrine) or received both methylprednisolone 40 mg IV + 20 Units of vasopressin as soon as possible after first dose of epinephrine. An additional 20 Units of vasopressin was given after each epinephrine dose for a maximum of 4 doses (total 80 units).
• The drugs/placebo vials were in a blinded study kit which was carried by a dedicated member of the cardiac arrest team.
• While there was a tiny statistical difference in primary outcome (achievement of ROSC favoring intervention), there were no meaningful differences in secondary outcomes (survival to 30 days, with or without favorable outcomes neurologically as measured by modified Rankins, or other organs as measured by SOFA score).
• I have concerns regarding ethical and logistical issues of getting consent for a clinical situation of cardiac arrest.
• This will not change my practice.

Chu Review: Meier 2023’s review on surgical vs non-surgical management of appendicitis in Americans > 65 yo

Back when I was in med school (2013-2017), I learnt that acute appendicitis was straight to surgery, do not pass Go, do not collect $200. When I was in residency (2017-2020), there was some discussion in the amongst the consultant surgeons and their literature about who might benefit from medical management, especially as surgery itself is not a purely benign process. There’s the consideration of exacerbation of underlying medical conditions, technical requirements for certain patients (location of the appendix, body weight, frailty, etc.), the fact that most people don’t like the idea of being stabbed for medical purposes, risks of anesthesia, intubation, etc. These guys noticed that most of the literature left off for patients older than their mid-60’s and wanted to do a review of outcomes in these patients.

Side note, why am I, an ER doc, reading other specialty’s journals like JAMA and its sub-issues? First off, because it’s cool, duh, plus as an ER doc, I have to be able to talk shop with every other specialty out there and have a conversation with them.

Meier, J, et al. 2023. Outcomes of Nonoperative vs Operative Management of Acute Appendicitis in Older Adults in the US. JAMA Surgery. doi:10.1001/jamasurg.2023.0284

https://jamanetwork.com/journals/jamasurgery/fullarticle/2802834

One Liner: Landmark trials for non-op mgmt. of acute appendicitis focused mainly on younger adults, there is a need for further evaluation of surgery vs non-surgery in > 65 yo adults with acute appendicitis; will not change my practice as I am not a surgeon.

Brief Summary:

• PICO: In patients who are > 65 yo with acute appendicitis, is the intervention of non-operative management compared to operative management, lead to a difference in outcomes of “complications” in the operative management population as post operative complications, and in non-operative management population as need for procedure that occurred more than 1 day after admission.

• Previous landmark trials that evaluate non-op mgmt. of acute appendicitis focused mainly on younger adults with minimal comorbidities, with older adults > 65 yo being minimally represented. However, many surgeons nowadays are still trialing non-op management of older adults, based on those previous landmark trials.

• This was a retrospective cohort study that reviewed national surgical databases in the United States to see if there was a meaningful difference in the risk of complications between surgical and non-op mgmt. of acute appendicitis.
• Primary outcomes were divided between Surgical and Non-Surgical
  • Surgical complications were usual post-op issues like infections, thromboembolism, wound issues.
  • Non-op complications were essentially “they wound up needing a procedure anyways.”
  • Secondary outcomes were things like hospital LOS, financial cost, and mortality.

• In the > 65 yo group, the non-op group had slight decrease in morbidity, slight incresae in mortality, increased hospital LOS and higher hospital cost, and hypothetical risk of increased rate of missed appendix cancer.

• The risk of complication w greater with surgery for above and below 65 yo, but not very statistically different (odds ratio very close to 1).

• Main limitation of this study were this being a retrospective study requiring certain statistical assumptions, based on chart reviews and ICD codes.

• Main strengths of this study included good definitions of complications, large national database. Authors state (and I agree) that this represents enough of a starting point to recommend RCT’s.

• Will not change my practice directly, as I am not a surgeon.

Read more: Chu Review: Meier 2023’s review on surgical vs non-surgical management of appendicitis in Americans > 65 yo