APT: Hypertension
This week we will be looking at hypertension, from diagnosis in the outpatient setting to management in the inpatient setting. Please check out the 2017 ACC HTN guidelines a NEJM article on intensive vs liberal BP control (Sprint Trial). There are additional resources below you may find helpful.
Additional Resources
Hypertension
Definitions:
Normal: SBP <120 and DBP <80
Elevated: SBP 120-129 and DBP <80
Stage 1 HTN: SBP 130-139 or DBP 80-89
Stage 2 HTN: SBP ≥ 140 or DBP ≥90
End Organ Damage
Brain - stroke sequelae, multi-infarct dementia
Eye- retinopathy, hemorrhage, papilledema
Heart - diastolic dysfunction, LVH, obstructive cardiomyopathy, HFpEF, coronary atherosclerosis, MI, HFrEF
Kidney- CKD, Albuminuria, reduced GFR, end stage kidney failure
Vascular - aortic aneurysm (ascending, descending), atherosclerotic occlusive disease with limb or organ ischemia, aortic dissection
Hypertensive emergency: BP >180/>120 with evidence of end organ damage
Special Considerations
IPH/SAH - SBP goal < 140 ASAP
Aortic dissection: SBP <120 ASAP
General principals:
1st Hour: decrease BP < 25%
4-6 hours: BP < 160/100
>24-48 hours: BP < 140/90
APT: Diabetes
This week we will be covering diabetes mellitus.
Below are some helpful articles. Please check out the land mark trial RABBIT-2, as well as a retrospective review explaining why we do what we do in the inpatient setting (Krinsley). In addition there is a review on oral diabetic agents and a short article on the use of sliding scale as monotherapy you may find helpful.
APT: HIV and AIDS
In preparation for this Friday’s APT, please read the below articles on HIV management, PCP, and a review from The Lancet. For those that want additional information, articles have been attached regarding Toxoplasmosis, Cryptococcus, AIDS info guidelines, and an article from NJEM. The Four Decades article is a short read, and the AIDS info recs is a short read if checking the highlighted sections.
Optional Reading
APT: GI Bleed
The dreaded GI bleeder… This week we will be discussing management of upper GI bleeding. Please review the ACG guidelines below. In addition there are two other articles you may find helpful. There is a study looking at liberal vs conservative transfusion guidelines and the best way to administer PPI for those with GI bleeding.
APT: Acute Kidney Injury
This Friday we will be discussing acute kidney injury. Please read the article of the Annals of Internal Medicine on AKI. We also included optional reading from the Choosing Wisely series.
Optional Reading:
APT: Antibiotics
This week we will be covering a bread and butter topic every internist needs to know about, antibiotics. In preparation we have pulled two of the IDSA guidelines to review. First is the IDSA skin and soft tissue infection guidelines, which most of you should be familiar with. Please review the material in this article (you don’t need to read it cover to cover). In addition, we have provided the IDSA guidelines on cystitis and pyelonephritis to help you prepare. We look forward to fighting some bugs with you on Friday!
APT: Endocarditis
This week we will review Endocarditis. In preparation we are asking you to read the JAMA review of the AHA guidelines. The articles on native valve endocarditis and IE in patients with IVDU are short articles that may also be helpful. Also included are the AHA guidelines for Endocarditis which may be a helpful resource.
APT: Liver
This week we will be discussing the Liver and Bile Collecting system. Please review NEJM review articles on cirrhosis, acute liver failure, and ACG clinical guidelines for LFT interpretation/work up to help prepare.
Approach to Liver chemistries:
ALT: 33 (males), 25 (females), ALP: 115 (males), 100 (females)
Hepatocellular: ALT and AST both up
Cholestatic: ALP up and also direct hyperbilirubinemia
Infiltrative: ASLT up without significant bilirubin or AST or ALT elevation
Non-hepatic: Isolated AST elevated, indirect hyperbilirubinemia
Any degree of AST/ALT elevated:
meds/toxins (aceteaminophen, certain abx, INH, MTX, NSAIDs, heparin, amiodarone, steroids, augment, sulfa drugs, allopurinol, etc)
Alcohol related (alcoholic hepatitis usually >2:1 AST:ALT ratio)
viral infections (Hep A-E, EBV, CMV, VZV, HSV)
Sepsis /ischemia
Biliary obstruction (mixed picture)
NAFLD (usually AST and ALT elevated but <4x ULN)
If above: Workup includes, but not limited to:
stop offending medications/toxins
viral hepatitis serologies
RUQ US (steatosis, cirrhosis, fibroscan)
ANA, ASMA, LKM-1, IgG, Ceruloplasmin, urinary copper, Fe/TIBC >45%, ferritin >200,
Extreme elevation (AST/ALT >1000s, indicates some acute process)
Ischemia (Shock, cardiac arrest, Budd-Chiari, usually AST/ALT goes up first then bilirubin increases)
Meds/toxins (acetaminophen toxicity)
Acute viral infection (Hep A-E, consider HBV reactivation)
autoimmune hepatitis
acute biliary obstruction
If above, workup includes, but not limited to
INR, assess for hepatic encephalopathy, acute liver injury/failure
stop offending meds/toxins, consider activated charcoal, N-acetylcysteine
viral serologies
RUQ US with dopplers
Cholestatic injury pattern (Increased ALP and biliriubin)
Biliary obstruction (Choledocholithiasis, malignancy, primary sclerosis cholangitis, chronic pancreatitis w/ strictures)
intrahepatic cholestasis: Medications (penicillin, cephalosporins, anabolic steroids, bactrim, TPN, sepsis, primary biliary cholangitis (PBC)
If above, workup with include, but not limited to
RUQ US for obstruction
MRCP or ERCP
+/- liver biopsy
Infiltrative pattern (primarily ALP elevation)
sarcoidosis or other granulomatosis (Tb)
Malignancy (lymphoma, mets to liver, HCC)
Amyloidosis
abscess
If above, workup includes, but not limited to
GGT, imaging with RUQ US or CT, MRCP
Consider SPEP + IgG4
+- liver biopsy
Acute Liver Failure
King’s College Criteria
Acetaminophen induced liver failure: pH <7.3, or ALL 3 of INR > 6.5, Cr > 3.4, grades 3-4 Hepatic encephlopathy
All other causes of ALF: INR >6.5 OR 3/5 of the following: age <10 or >40, Tbili >17, INR >3.5, time from jaundice to encephalopathy >7d, unfavorable etiology (Seronegative hepatitis, DILI, Wilson’s)
Decompensated Cirrhosis
APT: COPD
On October 18, we will be focusing on COPD for our Academic Half Day. In preparation there is a review article posted for pulmonary function tests. In addition, please review the GOLD Pocket guide. The guide itself is quite long, please focus on the diagnosis and management sections in the guide.
Indications for Noninvasive mechanical ventilation (at least one of the following)
Respiratory acidosis
Severe dyspnea with clinical signs suggestive of respiratory muscle fatigue, increased work of breathing, or both, accessory muscle use (paradoxical motion of abdomen, retraction of intercostal spaces)
Persistent hypoxemia despite supplemental oxygen therapy
SUMMARY
Classification of Airflow limitation severity in COPD
GOLD 1 (Mild): FEV1 ≥ 80% of predicted
GOLD 2 (Moderate): 50% ≤ FEV1 < 80%
GOLD 3 (Severe): 30% ≤ FEV1 < 50%
GOLD 4 (Very severe): FEV1 <30% of predicted
Triple therapy:
IMPACT Trial (Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD (nejm.org) : phase 3 RCT that compared effects of once daily triple therapy with LABA+LAMA+ICS vs: LABA/ICS or LABA/LAMA on COPD exacerbation
in contrast to FLAME trial which showed a benefit of LAMA-LABA over ICS-LABA for prevention of exacerbations
triple therapy led to significantly lower rates of moderate or severe COPD exacerbations and better lung function and quality of life
Long term supplemental O2 therapy
indicated for stable patients who have SaO2 ≤ 88% or PaO2 ≤ 55mHg
also indicated if PaO2 between 55 and 60mmHg if also evidence of pulmonary hypertension, CHF, polycthemia (Hct > 55%)
NEJM LOTT trial (A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation | NEJM) - patients with stable COPD and resting or exercise induced moderate desaturation, the prescription of long term O2 did NOT result in longer time to death or 1st hospitalization than no long term O2.
APT: Heart Failure
We will try not to get backed up this week while we discuss heart failure. In preparation, please review the below materials. If you get through that, there is additional reading you may found useful: the EVALUATE-HF and PROVE-HF trials as well as an editorial from JAMA discussing some of the reversibility of remodeling seen with ARNIs.