In the Literature

The Hospitalist. 2009 December;2009(12):

December 1, 2009 | The Hospitalist

Kelly Cunningham, MD ; Elizabeth Rice, MD ; Eduard Vasilevskis, MD ; Joshua Labrin, MD ; Kelly Sopko, MD ; Shelley Ellis, MD, MPH ; Sunil Kripalani, MD, MSc ; Section OF

This study is limited by its post-hoc identification and classification of patients using ICD-9-CM codes, which could have resulted in some misclassification. Also, this study includes only two teaching hospitals in an urban setting; the prevalence of hyponatremia might differ in other settings. Causality cannot be determined based on these results.

Bottom line: Hospitalized patients with hyponatremia have increased in-hospital and long-term mortality.

Citation: Waikar SS, Mount DB, Curhan GC. Mortality after hospitalization with mild, moderate, and severe hyponatremia. Am J Med. 2009;122(9):857-865.

Clopidogrel Plus Aspirin in Patients with Atrial Fibrillation Reduces Risk of Major Vascular Events

Clinical question: Does the addition of clopidogrel to aspirin therapy reduce the risk of major vascular events in patients with atrial fibrillation for whom vitamin K antagonists (VKAs) are unsuitable?

Background: Although VKAs reduce the risk of stroke in atrial fibrillation, many patients are unable to use VKAs and are treated with aspirin instead. The potential benefits of adding clopidogrel to aspirin therapy in this population are unknown.

Study design: Randomized controlled trial.

Setting: Five hundred eighty medical centers in 33 countries.

Synopsis: More than 7,500 patients with atrial fibrillation who were also at high risk for stroke were randomly assigned to receive either clopidogrel or placebo once daily. All patients also received aspirin at a dose of 75 mg to 100 mg daily. A major vascular event occurred in 6.8% of patients per year who received clopidogrel and in 7.6% of patients per year who received placebo (RR 0.89, 95% CI, 0.89-0.98, P=0.01). This reduction primarily was due to a reduction in stroke, which occurred in 2.4% of patients per year who received clopidogrel, compared with 3.3% of patients per year who received placebo (RR 0.72, 95% CI, 0.62-0.83, P<0.001).

Major bleeding occurred in 2% of patients per year who received clopidogrel and in 1.3% of patients per year who received placebo (RR 1.57, 95% CI, 1.29-1.92, P<0.001).

Bottom line: Adding clopidogrel to aspirin in patients with atrial fibrillation who are not eligible for VKAs decreases the risk of major vascular events, including stroke, but increases risk of major hemorrhage compared with aspirin alone.

Citation: ACTIVE Investigators, Connolly SJ, Pogue J, et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med. 2009;360(20):2066-2078.

Clinical Shorts

ALCOHOL CONSUMPTION AND CIGARETTE USE ARE RISKS FOR CHRONIC PANCREATITIS

A multicenter study using a self-report questionnaire to classify alcohol consumption and cigarette use in recurrent acute pancreatitis and chronic pancreatitis found that very heavy alcohol consumption and smoking were independent risks for chronic pancreatitis.

Citation: Yadav D, Hawes RH, Brand RE, et al. Alcohol consumption, cigarette smoking, and the risk of recurrent acute and chronic pancreatitis. Arch Intern Med. 2009;169(11):1035-1045.

HIGH HEMOGLOBIN TARGETS OFFER MINIMAL BENEFIT IN CHRONIC KIDNEY DISEASE

Meta-analysis of data from the 36-item short form (SF-36) suggests that targeting hemoglobin levels above 12g/dL in patients with chronic kidney disease leads to statistically small and clinically insignificant improvements in health-related quality of life.

Citation: Clement FM, Klarenbach S, Tonelli M, Johnson JA, Manns BJ. The impact of selecting a high hemoglobin target level on health-related quality of life for patients with chronic kidney disease: a systematic review and meta-analysis. Arch Intern Med. 2009;169(12):1104-1112.

PHARMACOLOGIC THROMBOEMBOLISM PROPHYLAXIS HAS NET BENEFIT

Meta-analysis shows that among at-risk general medical patients, unfractionated and low-molecular-weight heparin similarly reduced the rate of thromboembolism without increasing the rate of major bleeding compared with no prophylaxis.

Citation: Bump GM, Dandu M, Kaufman SR, Shojania KG, Flanders SA. How complete is the evidence for thromboembolism prophylaxis in general medicine patients? A meta-analysis of randomized controlled trials. J Hosp Med. 2009;4(5):289-297.

NO DIFFERENCE IN EARLY VERSUS DELAYED INTERVENTION IN MOST ACS PATIENTS

Multicenter randomized trial of patients with non-ST elevation acute coronary syndromes showed that an early intervention strategy was not superior to a delayed intervention strategy in preventing death, myocardial infarction, or stroke. The study did show an intervention strategy might provide benefit in high-risk patients.

Citation: Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009;360(21):2165-75.