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During Flu Season Risk of Heart Failure Rises
A study of > 450,000 adults has “confirmed the long-held notion” that flu and heart failure are connected. The Atherosclerosis Risk in Communities study (ARIC), led by a VA researcher, found influenza significantly increased the risk of hospitalization for heart failure.
Every flu season about 36,000 people die, and > 200,000 are hospitalized due to flu, which is known to be associated with a higher risk of cardiovascular events. Several mechanisms likely contribute: Some form of immunocompromise is thought to be a key link. But few studies, the researchers note, have explored the temporal association between influenza activity and hospitalizations, particularly those caused by heart failure.
In ARIC, the researchers analyzed hospitalization data for adults aged 35 to 84 years between 2010 and 2014 in geographically diverse communities in Mississippi, Minnesota, North Carolina, and Maryland. They correlated those data with reports of influenza activity from the CDC Surveillance Network.
A 5% monthly increase in influenza activity was associated with a 24% relative increase in heart failure hospitalization rates. Myocardial infarction hospitalizations did not rise significantly. The most pneumonia and influenza-associated deaths were during the 2012-2013 season, when influenza-like illness (ILI) activity was highest, and the fewest deaths occurred during 2011-2012, when ILI activity was lowest. The model suggests that in a month with high influenza activity, about 19% of hospitalizations could be attributable to influenza, the researchers say.
“The study’s findings support VA’s aggressive effort every year to provide veterans with influenza vaccine,” said VA Secretary Robert Wilkie. Although the flu season is winding down, he added, it is not too late for veterans—and others—to get vaccinated.
A study of > 450,000 adults has “confirmed the long-held notion” that flu and heart failure are connected. The Atherosclerosis Risk in Communities study (ARIC), led by a VA researcher, found influenza significantly increased the risk of hospitalization for heart failure.
Every flu season about 36,000 people die, and > 200,000 are hospitalized due to flu, which is known to be associated with a higher risk of cardiovascular events. Several mechanisms likely contribute: Some form of immunocompromise is thought to be a key link. But few studies, the researchers note, have explored the temporal association between influenza activity and hospitalizations, particularly those caused by heart failure.
In ARIC, the researchers analyzed hospitalization data for adults aged 35 to 84 years between 2010 and 2014 in geographically diverse communities in Mississippi, Minnesota, North Carolina, and Maryland. They correlated those data with reports of influenza activity from the CDC Surveillance Network.
A 5% monthly increase in influenza activity was associated with a 24% relative increase in heart failure hospitalization rates. Myocardial infarction hospitalizations did not rise significantly. The most pneumonia and influenza-associated deaths were during the 2012-2013 season, when influenza-like illness (ILI) activity was highest, and the fewest deaths occurred during 2011-2012, when ILI activity was lowest. The model suggests that in a month with high influenza activity, about 19% of hospitalizations could be attributable to influenza, the researchers say.
“The study’s findings support VA’s aggressive effort every year to provide veterans with influenza vaccine,” said VA Secretary Robert Wilkie. Although the flu season is winding down, he added, it is not too late for veterans—and others—to get vaccinated.
A study of > 450,000 adults has “confirmed the long-held notion” that flu and heart failure are connected. The Atherosclerosis Risk in Communities study (ARIC), led by a VA researcher, found influenza significantly increased the risk of hospitalization for heart failure.
Every flu season about 36,000 people die, and > 200,000 are hospitalized due to flu, which is known to be associated with a higher risk of cardiovascular events. Several mechanisms likely contribute: Some form of immunocompromise is thought to be a key link. But few studies, the researchers note, have explored the temporal association between influenza activity and hospitalizations, particularly those caused by heart failure.
In ARIC, the researchers analyzed hospitalization data for adults aged 35 to 84 years between 2010 and 2014 in geographically diverse communities in Mississippi, Minnesota, North Carolina, and Maryland. They correlated those data with reports of influenza activity from the CDC Surveillance Network.
A 5% monthly increase in influenza activity was associated with a 24% relative increase in heart failure hospitalization rates. Myocardial infarction hospitalizations did not rise significantly. The most pneumonia and influenza-associated deaths were during the 2012-2013 season, when influenza-like illness (ILI) activity was highest, and the fewest deaths occurred during 2011-2012, when ILI activity was lowest. The model suggests that in a month with high influenza activity, about 19% of hospitalizations could be attributable to influenza, the researchers say.
“The study’s findings support VA’s aggressive effort every year to provide veterans with influenza vaccine,” said VA Secretary Robert Wilkie. Although the flu season is winding down, he added, it is not too late for veterans—and others—to get vaccinated.
Coughing Won’t Pay the Bills
ANSWER
The correct interpretation includes normal sinus rhythm, biatrial enlargement, and right-axis deviation. Other findings include a prolonged QT interval and ST-T wave abnormalities in inferior and anterior distributions.
A P wave
A normal QTc interval is generally 350 to 440 ms; the patient’s QTc interval (477 ms) meets the criteria for prolonged QT. There are ST- and T-wave inversions in leads II, III, and aVF, consistent with inferior ischemia, with ST depressions in leads V3 and V4, which could suggest anterior ischemia. Such findings are also seen in a pulmonary disease pattern.
Further workup included a chest x-ray, laboratory testing, and an echocardiogram. The last revealed right lower lobe consolidation and a diffuse, dilated cardiomyopathy with mild mitral and tricuspid regurgitation.
ANSWER
The correct interpretation includes normal sinus rhythm, biatrial enlargement, and right-axis deviation. Other findings include a prolonged QT interval and ST-T wave abnormalities in inferior and anterior distributions.
A P wave
A normal QTc interval is generally 350 to 440 ms; the patient’s QTc interval (477 ms) meets the criteria for prolonged QT. There are ST- and T-wave inversions in leads II, III, and aVF, consistent with inferior ischemia, with ST depressions in leads V3 and V4, which could suggest anterior ischemia. Such findings are also seen in a pulmonary disease pattern.
Further workup included a chest x-ray, laboratory testing, and an echocardiogram. The last revealed right lower lobe consolidation and a diffuse, dilated cardiomyopathy with mild mitral and tricuspid regurgitation.
ANSWER
The correct interpretation includes normal sinus rhythm, biatrial enlargement, and right-axis deviation. Other findings include a prolonged QT interval and ST-T wave abnormalities in inferior and anterior distributions.
A P wave
A normal QTc interval is generally 350 to 440 ms; the patient’s QTc interval (477 ms) meets the criteria for prolonged QT. There are ST- and T-wave inversions in leads II, III, and aVF, consistent with inferior ischemia, with ST depressions in leads V3 and V4, which could suggest anterior ischemia. Such findings are also seen in a pulmonary disease pattern.
Further workup included a chest x-ray, laboratory testing, and an echocardiogram. The last revealed right lower lobe consolidation and a diffuse, dilated cardiomyopathy with mild mitral and tricuspid regurgitation.
For the past 5 days, a 57-year-old man with “the flu” hasn’t been able to work. This morning, he awoke with chest tightness but denies chest pain. Because work has been busy lately, he just wants an antibiotic to help get him back on the job.
His primary symptom is a persistent, nonproductive cough that prevents him from getting a good night’s sleep. Associated symptoms include rhinorrhea, myalgias and arthralgias, and (for the first 3 days of illness) a low-grade fever. He’s been coughing so hard and for so long that his chest has begun to hurt. His cough is aggravated when lying down and somewhat relieved when sitting upright. He denies wheezing. He presents with specific requests: a chest x-ray to rule out pneumonia and prescriptions for azithromycin and codeine/acetaminophen (the latter for cough suppression).
Past medical history is remarkable for chronic obstructive pulmonary disease (COPD) and chronic bronchitis. Six months ago, a pulmonary function test revealed an FEV1 of 76% and an FEV1/FVC of 60%. He has chronic, mild to moderate shortness of breath with exertion. He has never had pneumonia or any anginal symptoms. Past surgical history is remarkable for an open reduction and internal fixation repair of his right tibia and an appendectomy. Current medications include acetaminophen for fever. He has used an albuterol inhaler in the past but has not had one for more than a year. He has no known drug allergies.
The patient is a crane operator for a large construction business. He is divorced and has an adult son with whom he has no contact. He’s been smoking 1.5 to 2 packs a day since he was 16. He used recreational marijuana until his employer began conducting random drug screenings 3 years ago. He drinks about 2 six-packs of beer a week—most of it on the weekends.
Family history is positive for COPD (mother), acute abdominal aortic dissection (father), and myocardial infarction (paternal grandfather).
The review of systems is positive for myalgias and arthralgias, which have been exacerbated by his recent illness. He denies a productive cough and any changes in heart rhythm and bowel or bladder function. He has no neurologic symptoms.
His vital signs include a blood pressure of 164/96 mm Hg; pulse, 80 beats/min; respiratory rate, 18 breaths/min-1; O2 saturation, 92% on room air; and temperature, 99.8°F.
Physical exam reveals an anxious, tired man in mild distress. His weight is 164 lb and his height, 70 in. The HEENT exam reveals ill-fitting corrective contact lenses, disheveled hair, and a nicotine-stained beard and mustache. His teeth are in poor repair; however, none are loose or missing. The neck is supple, and there is no thyromegaly. There is jugular venous distention, but not to the angle of the jaw. His respirations are shallow, requiring the use of accessory muscles. Deep inhalation causes uncontrollable coughing. Although there is anterior-posterior chest wall enlargement, it is insufficient to consider the patient barrel chested. Auscultation reveals diffuse, coarse rhonchi and end-expiratory wheezing.
The cardiac exam reveals a regular rate and rhythm of 80 beats/min, with a soft diastolic murmur (grade II/VI) that is best heard along the left sternal border. There are no extra heart sounds or rubs. The abdomen is tender to deep palpation in the right upper quadrant, with no evidence of rebound to suggest peritonitis. There are no abdominal or femoral arterial bruits. The extremities demonstrate 2+ pulses bilaterally with 1+ pitting edema in the lower legs. The neurologic exam is grossly intact.
The previously undocumented murmur prompts you to order an ECG. It shows a ventricular rate of 83 beats/min; PR interval, 178 ms; QRS duration, 110 ms; QT/QTc interval, 406/477 ms; P axis, 67°; R axis, 126°; and T axis, –57°. What is your interpretation of this ECG?
Dark spots in multiple locations
The FP considered whether this was a case of metastatic melanoma based on the appearance of the dark lesions, but thought that 22 years was a long time for a primary cancer to metastasize. After obtaining informed consent, the FP performed a 4-mm punch biopsy of one of the lesions on the patient’s trunk. (See the Watch & Learn video on “Punch biopsy.”)
The FP sutured the area closed to minimize postoperative bleeding. The pathology report came back as metastatic melanoma. Unfortunately, melanoma can return even decades after the primary tumor is excised. The FP referred the patient to a medical oncologist who specialized in melanoma treatment. Unfortunately, the patient passed away within a year of the recurrent melanoma diagnosis.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.
To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
The FP considered whether this was a case of metastatic melanoma based on the appearance of the dark lesions, but thought that 22 years was a long time for a primary cancer to metastasize. After obtaining informed consent, the FP performed a 4-mm punch biopsy of one of the lesions on the patient’s trunk. (See the Watch & Learn video on “Punch biopsy.”)
The FP sutured the area closed to minimize postoperative bleeding. The pathology report came back as metastatic melanoma. Unfortunately, melanoma can return even decades after the primary tumor is excised. The FP referred the patient to a medical oncologist who specialized in melanoma treatment. Unfortunately, the patient passed away within a year of the recurrent melanoma diagnosis.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.
To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
The FP considered whether this was a case of metastatic melanoma based on the appearance of the dark lesions, but thought that 22 years was a long time for a primary cancer to metastasize. After obtaining informed consent, the FP performed a 4-mm punch biopsy of one of the lesions on the patient’s trunk. (See the Watch & Learn video on “Punch biopsy.”)
The FP sutured the area closed to minimize postoperative bleeding. The pathology report came back as metastatic melanoma. Unfortunately, melanoma can return even decades after the primary tumor is excised. The FP referred the patient to a medical oncologist who specialized in melanoma treatment. Unfortunately, the patient passed away within a year of the recurrent melanoma diagnosis.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.
To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
Epinephrine linked with more refractory cardiogenic shock after acute MI
Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.
Study design: A multicenter, prospective, randomized, double-blind study.
Setting: ICUs in nine French hospitals.
Synopsis: Adults (older than 18 years old) who suffered cardiogenic shock following successful revascularization after AMI were enrolled. Fifty-seven patients were randomly assigned to receive either norepinephrine or epinephrine with patients, nurses, and physicians unaware of which study drug was being used. The primary outcome variable was change in cardiac index within the first 72 hours, and refractory cardiogenic shock served as the main safety endpoint. This study was stopped early because of the higher risk of refractory cardiogenic shock noted in the epinephrine group, compared with that seen in the norepinephrine group (10 of 27 vs. 2 of 30; P = .011). There was no difference in evolution of cardiac index (P = .43) between the two groups. Potentially harmful metabolic and physiologic changes were noted in the epinephrine group including greater lactic acidosis and increased heart rate.
This study was underpowered for clinical endpoints because of the study’s early termination. It also did not include patients in cardiogenic shock from other causes, such as myositis or postcardiopulmonary bypass.
Bottom line: For patients in cardiogenic shock after AMI with successful reperfusion, epinephrine use was associated with increased refractory cardiogenic shock, compared with norepinephrine use.
Citation: Levy B et al. Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-82.
Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.
Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.
Study design: A multicenter, prospective, randomized, double-blind study.
Setting: ICUs in nine French hospitals.
Synopsis: Adults (older than 18 years old) who suffered cardiogenic shock following successful revascularization after AMI were enrolled. Fifty-seven patients were randomly assigned to receive either norepinephrine or epinephrine with patients, nurses, and physicians unaware of which study drug was being used. The primary outcome variable was change in cardiac index within the first 72 hours, and refractory cardiogenic shock served as the main safety endpoint. This study was stopped early because of the higher risk of refractory cardiogenic shock noted in the epinephrine group, compared with that seen in the norepinephrine group (10 of 27 vs. 2 of 30; P = .011). There was no difference in evolution of cardiac index (P = .43) between the two groups. Potentially harmful metabolic and physiologic changes were noted in the epinephrine group including greater lactic acidosis and increased heart rate.
This study was underpowered for clinical endpoints because of the study’s early termination. It also did not include patients in cardiogenic shock from other causes, such as myositis or postcardiopulmonary bypass.
Bottom line: For patients in cardiogenic shock after AMI with successful reperfusion, epinephrine use was associated with increased refractory cardiogenic shock, compared with norepinephrine use.
Citation: Levy B et al. Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-82.
Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.
Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.
Study design: A multicenter, prospective, randomized, double-blind study.
Setting: ICUs in nine French hospitals.
Synopsis: Adults (older than 18 years old) who suffered cardiogenic shock following successful revascularization after AMI were enrolled. Fifty-seven patients were randomly assigned to receive either norepinephrine or epinephrine with patients, nurses, and physicians unaware of which study drug was being used. The primary outcome variable was change in cardiac index within the first 72 hours, and refractory cardiogenic shock served as the main safety endpoint. This study was stopped early because of the higher risk of refractory cardiogenic shock noted in the epinephrine group, compared with that seen in the norepinephrine group (10 of 27 vs. 2 of 30; P = .011). There was no difference in evolution of cardiac index (P = .43) between the two groups. Potentially harmful metabolic and physiologic changes were noted in the epinephrine group including greater lactic acidosis and increased heart rate.
This study was underpowered for clinical endpoints because of the study’s early termination. It also did not include patients in cardiogenic shock from other causes, such as myositis or postcardiopulmonary bypass.
Bottom line: For patients in cardiogenic shock after AMI with successful reperfusion, epinephrine use was associated with increased refractory cardiogenic shock, compared with norepinephrine use.
Citation: Levy B et al. Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-82.
Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.
ICYMI: Anti-CD4 antibody maintains viral suppression in HIV patients post ART
according to results from a small, nonrandomized, open-label, phase 2 trial published in the New England Journal of Medicine (2019 Apr 17. doi: 10.1056/NEJMoa1802264).
We reported on this story at the 2017 Conference on Retroviruses & Opportunistic Infections before it was published in the journal. Find our coverage at the link below.
according to results from a small, nonrandomized, open-label, phase 2 trial published in the New England Journal of Medicine (2019 Apr 17. doi: 10.1056/NEJMoa1802264).
We reported on this story at the 2017 Conference on Retroviruses & Opportunistic Infections before it was published in the journal. Find our coverage at the link below.
according to results from a small, nonrandomized, open-label, phase 2 trial published in the New England Journal of Medicine (2019 Apr 17. doi: 10.1056/NEJMoa1802264).
We reported on this story at the 2017 Conference on Retroviruses & Opportunistic Infections before it was published in the journal. Find our coverage at the link below.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
ACP governmental affairs leaders discuss ACA, Title X
PHILADELPHIA – in a video interview conducted during the annual meeting of the American College of Physicians.
Robert B. Doherty, the ACP’s senior vice president, governmental affairs and public policy, and Shari M. Erickson, the organization’s vice president of governmental affairs and medical practice, addressed the future of the Affordable Care Act (ACA), cuts to the funding of Title X clinics, and the National Rifle Association’s urging of Congress to vote against the Violence Against Women Reauthorization Act.
“We’re very, very concerned by a decision by a Texas judge that, if upheld on appeal, would gut the entire ACA and the decision by the administration not to defend any part of the ACA,” said Mr. Doherty.
Ms. Erikson later discussed a final rule released by the administration that she said “significantly impacts access to care for women,” particularly for those in low-income and underserved areas who may be seen by clinics that receive Title X funding.
She also addressed the rule’s effects on federally qualified health centers and other health clinics near Title X–funded clinics that are forced to close.
On a positive note, Mr. Doherty noted that the ACP is supporting legislation that has been introduced in the House to stabilize the current insurance markets.
Mr. Doherty and Ms. Erikson concluded by discussing an ACP initiative focused on reducing administrative burden for ACP members.
PHILADELPHIA – in a video interview conducted during the annual meeting of the American College of Physicians.
Robert B. Doherty, the ACP’s senior vice president, governmental affairs and public policy, and Shari M. Erickson, the organization’s vice president of governmental affairs and medical practice, addressed the future of the Affordable Care Act (ACA), cuts to the funding of Title X clinics, and the National Rifle Association’s urging of Congress to vote against the Violence Against Women Reauthorization Act.
“We’re very, very concerned by a decision by a Texas judge that, if upheld on appeal, would gut the entire ACA and the decision by the administration not to defend any part of the ACA,” said Mr. Doherty.
Ms. Erikson later discussed a final rule released by the administration that she said “significantly impacts access to care for women,” particularly for those in low-income and underserved areas who may be seen by clinics that receive Title X funding.
She also addressed the rule’s effects on federally qualified health centers and other health clinics near Title X–funded clinics that are forced to close.
On a positive note, Mr. Doherty noted that the ACP is supporting legislation that has been introduced in the House to stabilize the current insurance markets.
Mr. Doherty and Ms. Erikson concluded by discussing an ACP initiative focused on reducing administrative burden for ACP members.
PHILADELPHIA – in a video interview conducted during the annual meeting of the American College of Physicians.
Robert B. Doherty, the ACP’s senior vice president, governmental affairs and public policy, and Shari M. Erickson, the organization’s vice president of governmental affairs and medical practice, addressed the future of the Affordable Care Act (ACA), cuts to the funding of Title X clinics, and the National Rifle Association’s urging of Congress to vote against the Violence Against Women Reauthorization Act.
“We’re very, very concerned by a decision by a Texas judge that, if upheld on appeal, would gut the entire ACA and the decision by the administration not to defend any part of the ACA,” said Mr. Doherty.
Ms. Erikson later discussed a final rule released by the administration that she said “significantly impacts access to care for women,” particularly for those in low-income and underserved areas who may be seen by clinics that receive Title X funding.
She also addressed the rule’s effects on federally qualified health centers and other health clinics near Title X–funded clinics that are forced to close.
On a positive note, Mr. Doherty noted that the ACP is supporting legislation that has been introduced in the House to stabilize the current insurance markets.
Mr. Doherty and Ms. Erikson concluded by discussing an ACP initiative focused on reducing administrative burden for ACP members.
REPORTING FROM INTERNAL MEDICINE 2019
Role of Diet in Treating Skin Conditions
