Abstracts from Medical Literature for the Geriatrics Practitioner

Click here to download full article in PDF

NATIONAL TRENDS IN ANTIARRHYTHMIC AND ANTITHROMBOTIC MEDICATION USE IN ATRIAL FIBRILLATION

Atrial fibrillation is the most common significant cardiac arrhythmia affecting about 2.3 million adults in the United States. Although atrial fibrillation has been the focus of many clinical trials, it remains unclear whether recent clinical practice has changed in accordance with published recommendations. The authors examined trends in the medical therapy of atrial fibrillation in the United States from 1991 to 2000. They analyzed data from 1355 patients with atrial fibrillation from the National Ambulatory Medical Care Survey. They assessed trends in use of medications for ventricular rate control (digoxin, beta-blockers, and calcium channel blockers), sinus rhythm maintenance (antiarrhythmics), and thromboembolism prevention (oral anticoagulants and aspirin). The authors hypothesized that digoxin use would decline with increased use of beta-blockers and calcium channel blockers, that there would be a growing interest in use of medications sinus rhythm maintenance, and that anticoagulant use would increase, especially in patients at risk for stroke. Investigators found that the overall medication use for ventricular rate control decreased from 72% in 1991-1992 to 56% in 1999-2000 due to declining digoxin use. Beta-blocker and calcium channel blocker use remained unchanged. Although there was no change in overall sinus rhythm medication use over time, amiodarone hydrochloride use increased from 0.2% to 6.4%, while quinidine use decreased from 5.0% to 0.0%. The use of oral anticoagulants increased (28% to 41%), most significantly in patients aged 80 years and older (14% to 48%). However, only 46.5% of patients at high risk for stroke were taking anticoagulants in 1999-2000. The authors concluded that digoxin use in atrial fibrillation decreased over time, without concomitant increases in beta-blocker or calcium channel blocker use. Amiodarone replaced quinidine as the dominant sinus rhythm medication. Although oral anticoagulant use increased over time, less than half of the patients at high risk for stroke were anticoagulated.

Fang MC, Stafford RS, Ruskin JN, Singer DE. National trends in antiarrhythmic and antithrombotic medication use in atrial fibrillation. Arch Intern Med 2004;164:55-60.

ADDITIVE BENEFITS OF PRAVASTATIN AND ASPIRIN TO DECREASE RISKS OF CARDIOVASCULAR DISEASE

Randomized trials of secondary prevention have shown pravastatin sodium and aspirin to reduce the risk of cardiovascular disease. Regulatory authorities worldwide, including the FDA, have approved the use of pravastatin and aspirin for the secondary prevention of cardiovascular disease. Pravastatin has a delayed antiatherogenic effect, and aspirin has an immediate antiplatelet effect, which suggests the possibility of additive clinical benefits. Variable data were collected from five randomized trials of secondary prevention with pravastatin (40 mg/d) with varying aspirin use involving 73,900 patient-years of observation. The authors examined whether pravastatin and aspirin have additive clinical benefits in two large trials, the Long-Term Intervention With Pravastatin in Ischaemic Disease trial and the Cholesterol and Recurrent Events trial. They performed meta-analyses of these two trials and of three smaller angiographic trials that collected clinical endpoints. Multivariate models were used in all analyses to adjust for a large number of cardiovascular disease risk factors. The authors found that the individual trials and all meta-analyses demonstrated similar additive benefits of pravastatin and aspirin on cardiovascular disease. The relative risk reductions for fatal or nonfatal myocardial infarction were 31% for pravastatin plus aspirin versus aspirin alone, and 26% for pravastatin plus aspirin compared to pravastatin alone. The relative risk reductions for ischemic stroke were 29% and 31%. For coronary heart disease death, nonfatal myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, or ischemic stroke, the relative risk reductions were 24% and 13%. The authors concluded that more extensive and appropriate combined use of statins and aspirin in the secondary prevention of cardiovascular disease will avoid numerous premature deaths.

Hennekens CH, Sacks FM, Tonkin A, Jukema JW, Byington RP, Pitt B, Berry DA, Berry SM, Ford NF, Walker AJ, Natarajan K, Sheng-Lin C, Fiedorek FT, Belder R. Additive benefits of pravastatin and aspirin to decrease risks of cardiovascular disease: Randomized and observational comparisons of secondary prevention trials and their meta-analyses. Arch Intern Med 2004;164:40-44.

IS SIGNED CONSENT FOR INFLUENZA OR PNEUMOCOCCAL POLYSACCHARIDE VACCINATION REQUIRED?

Every year, 18,000 or more deaths and almost 65,000 hospitalizations occur from complications of influenza and pneumococcal disease, mostly in elderly persons, despite the availability of vaccines. Of the 36,000 deaths that occur among elderly patients per year due to pneumococcal infection, half of them could be prevented with vaccination. While the vaccines are 70-90% effective in preventing illness, the rate of vaccination is far below the Health People 2010 goal for older adults. Obtaining consent prior to administering these vaccines represents an obstacle to achieving this goal and of widespread vaccination. Many health care providers and institutions currently require signed consent before administering these vaccines because some believe it protects them from liability, while others believe it is mandated by federal or state law. However, signed consent is neither legally mandated nor a guarantee that the patient has given informed consent. This article expresses that vaccines should be treated as any other effective low-risk treatment prescribed to prevent adverse events. Furthermore, requiring signed consent before administering these low-risk, high-benefit vaccines is inconsistent with the current practice of not requiring signed consent before prescribing other common treatments (eg, antibiotic treatment), whose risk levels are the same or higher. It is suggested that health care providers should use the Vaccine Information Sheets developed by the Centers for Disease Control and Prevention to inform patients about the risks and benefits associated with the influenza and pneumococcal polysaccharide vaccines.

Kissam S, Gifford DR, Patry G, Bratzler DW. Is signed consent for influenza or pneumococcal polysaccharide vaccination required? Arch Intern Med 2004;164(1):13-16.

THE COMPREHENSIVE CARE TEAM

There are few data regarding the use of palliative care for outpatients continuing to pursue treatment of their underlying disease, or whether outpatient palliative medicine consultation teams improve clinical outcomes. Quality-of-life care requires attention to the physical, psychological, social, and spiritual well-being, advance care planning, and preparation for death. Hospice care follows a transitional model of palliation where healing attempts are replaced with comfort care, particularly by patients who have diseases with relatively predictable prognoses. However, most patients die of chronic illnesses that do not have predictable outcomes. A more extensive model of palliative medicine should offer aggressive symptom management and comprehensive care to the numerous outpatients continuing to pursue treatment or a cure for their disease. These investigators conducted a 1-year controlled trial involving 50 intervention patients and 40 control patients in a general medicine outpatient clinic. Patients with advanced congestive heart failure, chronic obstructive pulmonary disease, or cancer who had a prognosis ranging from 1-5 years were referred by primary care physicians. In the intervention group, primary care physicians received various palliative care team consultations, and patients received advance care planning, psychosocial support, and family caregiver training. Clinical and health care utilization outcomes were assessed at 6 and 12 months. Both groups were similar at baseline. After the intervention, patients in the intervention group had less dyspnea and anxiety and improved quality of sleep and spiritual well-being, but no change in pain, depression, quality of life, or satisfaction with care. Few patients received recommended analgesic or antidepressant medications. Patients in the intervention group had decreased primary care and urgent care visits, and no increase in emergency department visits, specialty clinic visits, hospitalizations, or number of days in the hospital. The authors concluded that consultation by a palliative medicine team led to improved outcomes in dyspnea, anxiety, and spiritual well-being, but did not improve pain or depression. While palliative care for seriously ill outpatients can be effective, obstacles to implementation should be examined.

Rabow MW, Dibble SL, Pantilat SZ, McPhee SJ. The comprehensive care team: A controlled trial of outpatient palliative medicine consultation. Arch Intern Med 2004;164:83-91.

(Annals of Long-Term Care:Clinical Care and Aging 2004;12[4]:39-40)

Annals of Long-Term Care - ISSN: 1524-7929 - Volume 12 - Issue 04 - April 2004