William E. Golden, MD

Background

Lung cancer is the leading cause of cancer death among men and women in the United States and will account for an estimated 160,000 deaths in 2012. The average 5-year survival for lung cancer is approximately 16%, among the poorest of all cancers. Studies have not shown a significant decrease in lung cancer mortality using chest x-ray (CXR) with and without sputum cytology.

However, the American Cancer Society recently published guidelines for lung cancer screening based on additional data from the National Lung Screening Trial (NLST), which reviewed the utility of low-dose computed tomography (LD-CT) for lung cancer screening.

A survey of 962 primary care physicians in 2006-2007 found that 25% of those surveyed believed that one or more of the national expert groups recommend screening asymptomatic patients for lung cancer. More than 50% of those surveyed had ordered a CXR, and nearly 25% had ordered LD-CT for lung cancer screening of asymptomatic patients in the last 12 months.

Conclusions

NLST randomized patients to annual LD-CT vs. annual CXR over 3 years, with results showing a 20% reduction in cancer death and a 6.7% reduction in death from all causes in the LD-CT arm. Two other randomized, controlled trials using the same endpoints but shorter follow-up were unable to demonstrate this same reduction.

Limitations and harms associated with LD-CT include the psychological stress and anxiety associated with abnormal results, false-positive test results, incidental findings outside of the lung, and morbidity/mortality associated with further diagnostic evaluations in patients with and without lung cancer.

A total of 39% of individuals experienced at least one abnormal CT scan over the 3 years of screening, and most of these patients needed additional imaging to determine the significance of the identified abnormalities. A total of 2.7% of patients ultimately found not have lung cancer underwent invasive procedures for further evaluation, with a complication rate of 0.06%. This is in comparison to the 11.2% complication rate for invasive procedures in patients who were subsequently diagnosed with lung cancer. Radiation exposure was not reported.

A total of 7.5% of participants were found to have incidental findings outside the lung fields on their screening imaging. Currently, there is insufficient evidence to evaluate the potential for overdiagnosis of lung cancer with LD-CT.

The average NLST participant was 62 years old, with approximately a 50-pack-year smoking history. The NLST conclusions suggests LD-CT screening is beneficial in men and women aged 55-74 years who are in reasonably good health, are current smokers or former smokers having quit within the past 15 years, and have a 30 or more pack-year smoking history.

Several studies have shown evidence of higher rates of smoking cessation in patients who have chosen to participate in lung cancer screening programs using LD-CT. A community-based screening program for oral, head, and neck cancer showed some increase in smoking cessation, but other programs targeting lung cancer screening have not replicated this data.

Few insurance programs provide coverage for LD-CT performed for lung cancer screening.

Implementation

The American Cancer Society lung cancer screening guidelines recommend that clinicians initiate a discussion about lung cancer screening with their patients aged 55-74 years who are in reasonably good health, are current smokers or former smokers who quit within the past 15 years, and have a 30 or more pack-year smoking history. Adults who choose to be screened should have annual LD-CT imaging until the age of 74 years.

Adults who choose to undergo lung cancer screening by LD-CT should be referred to an organized screening program. If such a program is not available, then referral should be made to a center that performs a reasonably high volume of CT scans, diagnostics tests, and lung cancer cases. If this is not available, or if the patient is unwilling to travel to a location where this is possible, then screening is not recommended.

Smoking cessation must remain a highest priority for all patients who are currently smoking. LD-CT screening should not be seen as an alternative to smoking cessation.

The American College of Chest Physicians, the American Society of Clinical Oncology, and the American Lung Association also suggest LD-CT screening based on similar NLST criteria.

The National Comprehensive Cancer Network recommends annual LD-CT for persons who meet NSLT entry criteria and for individuals 50 years or older with a smoking history of 20 or more pack-years who have one additional known risk factor for lung cancer.

The American Association for Thoracic Surgery recommends annual lung cancer screening with LD-CT for adults aged 55-79 years with a 30 pack-year history of smoking, annual screening beginning at age 50 years for adults with a 20-pack-year history and an additional calculated cumulative 5-year risk of developing lung cancer of 5% or greater. The 5-year cumulative risk is in conformity with the U.K. Lung Cancer Screening Trial, which uses the Liverpool Lung Project to calculate risk.

The United States Preventative Services Task Force recommendation (most recently updated in 2004) is that the evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with LD-CT, CXR, sputum cytology, or a combination of these tests. The USPSTF recommendation has not been revised based on the NLST study. However, the task force is compiling evidence, and a draft of its most current recommendations will be available for public review in 2013.

All decisions regarding lung cancer screening must include an open discussion between physicians and their patients regarding the potential benefits and harms of screening, including false-positive results, the psychological effects of those results, and potential complications related to further diagnostic evaluation. The financial burden to the patient must also be included in this discussion, as initial screening is rarely an insurance-covered benefit.

References

• Wender, R., et al. American Cancer Society lung cancer screening guidelines (CA Cancer J. Clin. 2013;63:106-17).

• Klabude, C., et al. Lung cancer screening practice of primary care physicians: results from a national survey (Ann. Fam. Med. 2012;10:102-10).

• Humphrey, L.L., Teutsch, S., Johnson, M.S. Lung cancer screening with sputum cytologic examination, chest radiography, and computed tomography: an update from the U.S. Preventive Services Task Force (Ann. Intern. Med. 2004;140:740-53).

• Bize, R., Burnand, B., Mueller, Y., Rège-Walther, M., Camain, J.Y., Cornuz, J. Biomedical risk assessment as an aid for smoking cessation (Cochrane Database Syst. Rev. 2012;12:CD004705).

• Ferketich, A.K., Otterson, G.A., King, M., Hall, N., Browning, K.K., Wewers, M.E. A pilot test of a combined tobacco dependence treatment and lung cancer screening program (Lung Cancer 2012;76:211-5).

• van der Aalst, C.M., de Koning, H.J., van den Bergh, K.A., Willemsen, M.C., van Klaveren, R.J. The effectiveness of computer-tailored smoking cessation intervention for participants in lung cancer screening: a randomized control trial (Lung Cancer 2012;76:204-10).

Dr. Vancil is an assistant professor of internal medicine at the University of Arkansas, Little Rock. Dr. Golden is medical director of Arkansas Medicaid and professor of medicine and public health at the University of Arkansas. Dr. Hopkins is director of the division of general internal medicine at the University of Arkansas. E-mail them at imnews@frontlinemedcom.com. They reported having no relevant financial conflicts.

Background

Lung cancer is the leading cause of cancer death among men and women in the United States and will account for an estimated 160,000 deaths in 2012. The average 5-year survival for lung cancer is approximately 16%, among the poorest of all cancers. Studies have not shown a significant decrease in lung cancer mortality using chest x-ray (CXR) with and without sputum cytology.

However, the American Cancer Society recently published guidelines for lung cancer screening based on additional data from the National Lung Screening Trial (NLST), which reviewed the utility of low-dose computed tomography (LD-CT) for lung cancer screening.

A survey of 962 primary care physicians in 2006-2007 found that 25% of those surveyed believed that one or more of the national expert groups recommend screening asymptomatic patients for lung cancer. More than 50% of those surveyed had ordered a CXR, and nearly 25% had ordered LD-CT for lung cancer screening of asymptomatic patients in the last 12 months.

Conclusions

NLST randomized patients to annual LD-CT vs. annual CXR over 3 years, with results showing a 20% reduction in cancer death and a 6.7% reduction in death from all causes in the LD-CT arm. Two other randomized, controlled trials using the same endpoints but shorter follow-up were unable to demonstrate this same reduction.

Limitations and harms associated with LD-CT include the psychological stress and anxiety associated with abnormal results, false-positive test results, incidental findings outside of the lung, and morbidity/mortality associated with further diagnostic evaluations in patients with and without lung cancer.

A total of 39% of individuals experienced at least one abnormal CT scan over the 3 years of screening, and most of these patients needed additional imaging to determine the significance of the identified abnormalities. A total of 2.7% of patients ultimately found not have lung cancer underwent invasive procedures for further evaluation, with a complication rate of 0.06%. This is in comparison to the 11.2% complication rate for invasive procedures in patients who were subsequently diagnosed with lung cancer. Radiation exposure was not reported.

A total of 7.5% of participants were found to have incidental findings outside the lung fields on their screening imaging. Currently, there is insufficient evidence to evaluate the potential for overdiagnosis of lung cancer with LD-CT.

The average NLST participant was 62 years old, with approximately a 50-pack-year smoking history. The NLST conclusions suggests LD-CT screening is beneficial in men and women aged 55-74 years who are in reasonably good health, are current smokers or former smokers having quit within the past 15 years, and have a 30 or more pack-year smoking history.

Several studies have shown evidence of higher rates of smoking cessation in patients who have chosen to participate in lung cancer screening programs using LD-CT. A community-based screening program for oral, head, and neck cancer showed some increase in smoking cessation, but other programs targeting lung cancer screening have not replicated this data.

Few insurance programs provide coverage for LD-CT performed for lung cancer screening.

Implementation

The American Cancer Society lung cancer screening guidelines recommend that clinicians initiate a discussion about lung cancer screening with their patients aged 55-74 years who are in reasonably good health, are current smokers or former smokers who quit within the past 15 years, and have a 30 or more pack-year smoking history. Adults who choose to be screened should have annual LD-CT imaging until the age of 74 years.

Adults who choose to undergo lung cancer screening by LD-CT should be referred to an organized screening program. If such a program is not available, then referral should be made to a center that performs a reasonably high volume of CT scans, diagnostics tests, and lung cancer cases. If this is not available, or if the patient is unwilling to travel to a location where this is possible, then screening is not recommended.

Smoking cessation must remain a highest priority for all patients who are currently smoking. LD-CT screening should not be seen as an alternative to smoking cessation.

The American College of Chest Physicians, the American Society of Clinical Oncology, and the American Lung Association also suggest LD-CT screening based on similar NLST criteria.

The National Comprehensive Cancer Network recommends annual LD-CT for persons who meet NSLT entry criteria and for individuals 50 years or older with a smoking history of 20 or more pack-years who have one additional known risk factor for lung cancer.

The American Association for Thoracic Surgery recommends annual lung cancer screening with LD-CT for adults aged 55-79 years with a 30 pack-year history of smoking, annual screening beginning at age 50 years for adults with a 20-pack-year history and an additional calculated cumulative 5-year risk of developing lung cancer of 5% or greater. The 5-year cumulative risk is in conformity with the U.K. Lung Cancer Screening Trial, which uses the Liverpool Lung Project to calculate risk.

The United States Preventative Services Task Force recommendation (most recently updated in 2004) is that the evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with LD-CT, CXR, sputum cytology, or a combination of these tests. The USPSTF recommendation has not been revised based on the NLST study. However, the task force is compiling evidence, and a draft of its most current recommendations will be available for public review in 2013.

All decisions regarding lung cancer screening must include an open discussion between physicians and their patients regarding the potential benefits and harms of screening, including false-positive results, the psychological effects of those results, and potential complications related to further diagnostic evaluation. The financial burden to the patient must also be included in this discussion, as initial screening is rarely an insurance-covered benefit.

References

• Wender, R., et al. American Cancer Society lung cancer screening guidelines (CA Cancer J. Clin. 2013;63:106-17).

• Klabude, C., et al. Lung cancer screening practice of primary care physicians: results from a national survey (Ann. Fam. Med. 2012;10:102-10).

• Humphrey, L.L., Teutsch, S., Johnson, M.S. Lung cancer screening with sputum cytologic examination, chest radiography, and computed tomography: an update from the U.S. Preventive Services Task Force (Ann. Intern. Med. 2004;140:740-53).

• Bize, R., Burnand, B., Mueller, Y., Rège-Walther, M., Camain, J.Y., Cornuz, J. Biomedical risk assessment as an aid for smoking cessation (Cochrane Database Syst. Rev. 2012;12:CD004705).

• Ferketich, A.K., Otterson, G.A., King, M., Hall, N., Browning, K.K., Wewers, M.E. A pilot test of a combined tobacco dependence treatment and lung cancer screening program (Lung Cancer 2012;76:211-5).

• van der Aalst, C.M., de Koning, H.J., van den Bergh, K.A., Willemsen, M.C., van Klaveren, R.J. The effectiveness of computer-tailored smoking cessation intervention for participants in lung cancer screening: a randomized control trial (Lung Cancer 2012;76:204-10).

Dr. Vancil is an assistant professor of internal medicine at the University of Arkansas, Little Rock. Dr. Golden is medical director of Arkansas Medicaid and professor of medicine and public health at the University of Arkansas. Dr. Hopkins is director of the division of general internal medicine at the University of Arkansas. E-mail them at imnews@frontlinemedcom.com. They reported having no relevant financial conflicts.

Background

Lung cancer is the leading cause of cancer death among men and women in the United States and will account for an estimated 160,000 deaths in 2012. The average 5-year survival for lung cancer is approximately 16%, among the poorest of all cancers. Studies have not shown a significant decrease in lung cancer mortality using chest x-ray (CXR) with and without sputum cytology.

However, the American Cancer Society recently published guidelines for lung cancer screening based on additional data from the National Lung Screening Trial (NLST), which reviewed the utility of low-dose computed tomography (LD-CT) for lung cancer screening.

A survey of 962 primary care physicians in 2006-2007 found that 25% of those surveyed believed that one or more of the national expert groups recommend screening asymptomatic patients for lung cancer. More than 50% of those surveyed had ordered a CXR, and nearly 25% had ordered LD-CT for lung cancer screening of asymptomatic patients in the last 12 months.

Conclusions

NLST randomized patients to annual LD-CT vs. annual CXR over 3 years, with results showing a 20% reduction in cancer death and a 6.7% reduction in death from all causes in the LD-CT arm. Two other randomized, controlled trials using the same endpoints but shorter follow-up were unable to demonstrate this same reduction.

Limitations and harms associated with LD-CT include the psychological stress and anxiety associated with abnormal results, false-positive test results, incidental findings outside of the lung, and morbidity/mortality associated with further diagnostic evaluations in patients with and without lung cancer.

A total of 39% of individuals experienced at least one abnormal CT scan over the 3 years of screening, and most of these patients needed additional imaging to determine the significance of the identified abnormalities. A total of 2.7% of patients ultimately found not have lung cancer underwent invasive procedures for further evaluation, with a complication rate of 0.06%. This is in comparison to the 11.2% complication rate for invasive procedures in patients who were subsequently diagnosed with lung cancer. Radiation exposure was not reported.

A total of 7.5% of participants were found to have incidental findings outside the lung fields on their screening imaging. Currently, there is insufficient evidence to evaluate the potential for overdiagnosis of lung cancer with LD-CT.

The average NLST participant was 62 years old, with approximately a 50-pack-year smoking history. The NLST conclusions suggests LD-CT screening is beneficial in men and women aged 55-74 years who are in reasonably good health, are current smokers or former smokers having quit within the past 15 years, and have a 30 or more pack-year smoking history.

Several studies have shown evidence of higher rates of smoking cessation in patients who have chosen to participate in lung cancer screening programs using LD-CT. A community-based screening program for oral, head, and neck cancer showed some increase in smoking cessation, but other programs targeting lung cancer screening have not replicated this data.

Few insurance programs provide coverage for LD-CT performed for lung cancer screening.

Implementation

The American Cancer Society lung cancer screening guidelines recommend that clinicians initiate a discussion about lung cancer screening with their patients aged 55-74 years who are in reasonably good health, are current smokers or former smokers who quit within the past 15 years, and have a 30 or more pack-year smoking history. Adults who choose to be screened should have annual LD-CT imaging until the age of 74 years.

Adults who choose to undergo lung cancer screening by LD-CT should be referred to an organized screening program. If such a program is not available, then referral should be made to a center that performs a reasonably high volume of CT scans, diagnostics tests, and lung cancer cases. If this is not available, or if the patient is unwilling to travel to a location where this is possible, then screening is not recommended.

Smoking cessation must remain a highest priority for all patients who are currently smoking. LD-CT screening should not be seen as an alternative to smoking cessation.

The American College of Chest Physicians, the American Society of Clinical Oncology, and the American Lung Association also suggest LD-CT screening based on similar NLST criteria.

The National Comprehensive Cancer Network recommends annual LD-CT for persons who meet NSLT entry criteria and for individuals 50 years or older with a smoking history of 20 or more pack-years who have one additional known risk factor for lung cancer.

The American Association for Thoracic Surgery recommends annual lung cancer screening with LD-CT for adults aged 55-79 years with a 30 pack-year history of smoking, annual screening beginning at age 50 years for adults with a 20-pack-year history and an additional calculated cumulative 5-year risk of developing lung cancer of 5% or greater. The 5-year cumulative risk is in conformity with the U.K. Lung Cancer Screening Trial, which uses the Liverpool Lung Project to calculate risk.

The United States Preventative Services Task Force recommendation (most recently updated in 2004) is that the evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with LD-CT, CXR, sputum cytology, or a combination of these tests. The USPSTF recommendation has not been revised based on the NLST study. However, the task force is compiling evidence, and a draft of its most current recommendations will be available for public review in 2013.

All decisions regarding lung cancer screening must include an open discussion between physicians and their patients regarding the potential benefits and harms of screening, including false-positive results, the psychological effects of those results, and potential complications related to further diagnostic evaluation. The financial burden to the patient must also be included in this discussion, as initial screening is rarely an insurance-covered benefit.

References

• Wender, R., et al. American Cancer Society lung cancer screening guidelines (CA Cancer J. Clin. 2013;63:106-17).

• Klabude, C., et al. Lung cancer screening practice of primary care physicians: results from a national survey (Ann. Fam. Med. 2012;10:102-10).

• Humphrey, L.L., Teutsch, S., Johnson, M.S. Lung cancer screening with sputum cytologic examination, chest radiography, and computed tomography: an update from the U.S. Preventive Services Task Force (Ann. Intern. Med. 2004;140:740-53).

• Bize, R., Burnand, B., Mueller, Y., Rège-Walther, M., Camain, J.Y., Cornuz, J. Biomedical risk assessment as an aid for smoking cessation (Cochrane Database Syst. Rev. 2012;12:CD004705).

• Ferketich, A.K., Otterson, G.A., King, M., Hall, N., Browning, K.K., Wewers, M.E. A pilot test of a combined tobacco dependence treatment and lung cancer screening program (Lung Cancer 2012;76:211-5).

• van der Aalst, C.M., de Koning, H.J., van den Bergh, K.A., Willemsen, M.C., van Klaveren, R.J. The effectiveness of computer-tailored smoking cessation intervention for participants in lung cancer screening: a randomized control trial (Lung Cancer 2012;76:204-10).

Dr. Vancil is an assistant professor of internal medicine at the University of Arkansas, Little Rock. Dr. Golden is medical director of Arkansas Medicaid and professor of medicine and public health at the University of Arkansas. Dr. Hopkins is director of the division of general internal medicine at the University of Arkansas. E-mail them at imnews@frontlinemedcom.com. They reported having no relevant financial conflicts.

Background

Perioperative management of patients prescribed anticoagulant and/or antiplatelet medications poses a challenge affecting the care of roughly 250,000 patients in the United States annually. In February, the American College of Chest Physicians published updated clinical guidelines to assist physicians with these issues. This and the other articles in the 9th edition of the ACCP Antithrombotic Guidelines are useful sources for patient management regarding thromboembolism diagnosis, prevention, and treatment.

Conclusions

Perioperative anticoagulation management should be based on an assessment of the patient’s risk for venous thromboembolism (VTE) in the context of the risk for bleeding associated with a planned procedure.

No validated model has yet been developed to stratify patients treated with vitamin K antagonists into groups based on their risk for perioperative thrombosis and bleeding. The guideline suggests using a schema that identifies patients at greater than 10% annual risk for VTE as high risk and those at less than 5% annual risk for VTE as low risk, while recognizing that individual patient considerations may be more important than this stratification.

The risk for postoperative VTE associated with a particular procedure is not equivalent to the risk for thromboembolism associated with interruption of antithrombotic therapy, as the potential risk for arterial thrombosis as well as VTE must be considered when coumarins and antiplatelet medications are withheld.

Procedures associated with the highest risk for bleeding when perioperative anticoagulants/antithrombotics are used include urologic procedures; placement of pacemakers and implantable cardioverter defibrillators; endoscopic polypectomy (especially large sessile polyps); procedures on large vascular organs such as the liver, kidney, or spleen; bowel resections, cardiac surgery, major surgeries with tissue injury including joint replacements, cancer surgery, and reconstructive procedures; and intracranial/spinal surgeries.

While not evaluated in randomized trials, a standardized approach to perioperative anticoagulation is recommended in an effort to optimize patient outcomes. Suggestions include perioperative risk assessment at least 7 days prior to the procedure; patient/caregiver education; and medication calendars to optimize compliance; international normalized ratio (INR) measurement 1 day before surgery in patients requiring vitamin K antagonist (VKA) cessation; and routine assessment of postoperative hemostasis before resuming anticoagulants.

Implementation

When vitamin K antagonists must be withheld preoperatively, a 5-day hold interval is recommended. VKA may be resumed when adequate hemostasis is observed at 12-24 hours following the procedure.

Perioperative bridge anticoagulation is recommended in patients with mechanical valves, atrial fibrillation, and/or those with prior VTE whom are at high risk for thromboembolism.

An assessment of risk vs. benefit should be used to decide whether to implement bridge anticoagulation in patients with an intermediate 5%-10%/year risk for recurrent VTE. This assessment should incorporate the procedural risk for perioperative bleeding.

No bridging anticoagulation is recommended in patients at low risk, less than 5% recurrent VTE risk annually.

Patients requiring minor dental procedures at moderate risk of bleeding whom are chronically treated with VKA may have the VKA continued through the perioperative period and be treated with prohemostatic agents for bleeding prevention; alternatively, VKA may be held 2-3 days prior to the procedure and resumed afterward.

Patients who are receiving VKA treatment should have this continued through the perioperative period for minor dermatologic procedures and cataract surgery.

Patients who receive bridging anticoagulation with intravenous unfractionated heparin should have the heparin stopped 4-6 hours prior to the procedure. Patients receiving subcutaneous low-molecular weight heparin should receive their last preoperative dose 24 hours prior to the procedure. For procedures with a high bleeding risk, demonstrated hemostasis, and a 48-72 hour interval should elapse prior to resuming low-molecular weight heparin; a 24-hour interval is reasonable for procedures at lower bleeding risk.

Patients who are receiving aspirin for secondary cardiovascular prevention should have aspirin continued through the perioperative period for minor dental procedures, minor dermatologic procedures, or cataract surgery.

If possible, it is recommended that surgery and procedures be deferred for at least 6 weeks following implantation of bare-metal coronary stents and for at least 6 months following implantation of drug-eluting coronary stents. If it is not possible to defer procedures, it is recommended that dual antiplatelet medications be continued through the perioperative period. These patients are expected to have increased perioperative bleeding and must be monitored closely.

Patients who are treated with aspirin and whom are at moderate or greater risk for cardiovascular events should have aspirin continued through the perioperative period to aid in reduction of perioperative CV risk.

Aspirin should be continued through the perioperative period in patients with coronary artery disease requiring CABG. Clopidogrel should be stopped 5 days preoperatively and aspirin should be continued in patients previously treated with dual antiplatelet therapy who require CABG.

Reference

Douketis JD, et al., Perioperative Management of Antithrombotic Therapy in Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141 (2)(Suppl);e326S-350S.

William E. Golden, M.D., is professor of medicine and public health, and Robert H. Hopkins, M.D., is program director for the internal medicine/pediatrics combined residency program, both at the University of Arkansas, Little Rock. Write to them at imnews@elsevier.com. They reported having no conflicts of interest.

Background

Perioperative management of patients prescribed anticoagulant and/or antiplatelet medications poses a challenge affecting the care of roughly 250,000 patients in the United States annually. In February, the American College of Chest Physicians published updated clinical guidelines to assist physicians with these issues. This and the other articles in the 9th edition of the ACCP Antithrombotic Guidelines are useful sources for patient management regarding thromboembolism diagnosis, prevention, and treatment.

Conclusions

Perioperative anticoagulation management should be based on an assessment of the patient’s risk for venous thromboembolism (VTE) in the context of the risk for bleeding associated with a planned procedure.

No validated model has yet been developed to stratify patients treated with vitamin K antagonists into groups based on their risk for perioperative thrombosis and bleeding. The guideline suggests using a schema that identifies patients at greater than 10% annual risk for VTE as high risk and those at less than 5% annual risk for VTE as low risk, while recognizing that individual patient considerations may be more important than this stratification.

The risk for postoperative VTE associated with a particular procedure is not equivalent to the risk for thromboembolism associated with interruption of antithrombotic therapy, as the potential risk for arterial thrombosis as well as VTE must be considered when coumarins and antiplatelet medications are withheld.

Procedures associated with the highest risk for bleeding when perioperative anticoagulants/antithrombotics are used include urologic procedures; placement of pacemakers and implantable cardioverter defibrillators; endoscopic polypectomy (especially large sessile polyps); procedures on large vascular organs such as the liver, kidney, or spleen; bowel resections, cardiac surgery, major surgeries with tissue injury including joint replacements, cancer surgery, and reconstructive procedures; and intracranial/spinal surgeries.

While not evaluated in randomized trials, a standardized approach to perioperative anticoagulation is recommended in an effort to optimize patient outcomes. Suggestions include perioperative risk assessment at least 7 days prior to the procedure; patient/caregiver education; and medication calendars to optimize compliance; international normalized ratio (INR) measurement 1 day before surgery in patients requiring vitamin K antagonist (VKA) cessation; and routine assessment of postoperative hemostasis before resuming anticoagulants.

Implementation

When vitamin K antagonists must be withheld preoperatively, a 5-day hold interval is recommended. VKA may be resumed when adequate hemostasis is observed at 12-24 hours following the procedure.

Perioperative bridge anticoagulation is recommended in patients with mechanical valves, atrial fibrillation, and/or those with prior VTE whom are at high risk for thromboembolism.

An assessment of risk vs. benefit should be used to decide whether to implement bridge anticoagulation in patients with an intermediate 5%-10%/year risk for recurrent VTE. This assessment should incorporate the procedural risk for perioperative bleeding.

No bridging anticoagulation is recommended in patients at low risk, less than 5% recurrent VTE risk annually.

Patients requiring minor dental procedures at moderate risk of bleeding whom are chronically treated with VKA may have the VKA continued through the perioperative period and be treated with prohemostatic agents for bleeding prevention; alternatively, VKA may be held 2-3 days prior to the procedure and resumed afterward.

Patients who are receiving VKA treatment should have this continued through the perioperative period for minor dermatologic procedures and cataract surgery.

Patients who receive bridging anticoagulation with intravenous unfractionated heparin should have the heparin stopped 4-6 hours prior to the procedure. Patients receiving subcutaneous low-molecular weight heparin should receive their last preoperative dose 24 hours prior to the procedure. For procedures with a high bleeding risk, demonstrated hemostasis, and a 48-72 hour interval should elapse prior to resuming low-molecular weight heparin; a 24-hour interval is reasonable for procedures at lower bleeding risk.

Patients who are receiving aspirin for secondary cardiovascular prevention should have aspirin continued through the perioperative period for minor dental procedures, minor dermatologic procedures, or cataract surgery.

If possible, it is recommended that surgery and procedures be deferred for at least 6 weeks following implantation of bare-metal coronary stents and for at least 6 months following implantation of drug-eluting coronary stents. If it is not possible to defer procedures, it is recommended that dual antiplatelet medications be continued through the perioperative period. These patients are expected to have increased perioperative bleeding and must be monitored closely.

Patients who are treated with aspirin and whom are at moderate or greater risk for cardiovascular events should have aspirin continued through the perioperative period to aid in reduction of perioperative CV risk.

Aspirin should be continued through the perioperative period in patients with coronary artery disease requiring CABG. Clopidogrel should be stopped 5 days preoperatively and aspirin should be continued in patients previously treated with dual antiplatelet therapy who require CABG.

Reference

Douketis JD, et al., Perioperative Management of Antithrombotic Therapy in Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141 (2)(Suppl);e326S-350S.

William E. Golden, M.D., is professor of medicine and public health, and Robert H. Hopkins, M.D., is program director for the internal medicine/pediatrics combined residency program, both at the University of Arkansas, Little Rock. Write to them at imnews@elsevier.com. They reported having no conflicts of interest.

Background

Perioperative management of patients prescribed anticoagulant and/or antiplatelet medications poses a challenge affecting the care of roughly 250,000 patients in the United States annually. In February, the American College of Chest Physicians published updated clinical guidelines to assist physicians with these issues. This and the other articles in the 9th edition of the ACCP Antithrombotic Guidelines are useful sources for patient management regarding thromboembolism diagnosis, prevention, and treatment.

Conclusions

Perioperative anticoagulation management should be based on an assessment of the patient’s risk for venous thromboembolism (VTE) in the context of the risk for bleeding associated with a planned procedure.

No validated model has yet been developed to stratify patients treated with vitamin K antagonists into groups based on their risk for perioperative thrombosis and bleeding. The guideline suggests using a schema that identifies patients at greater than 10% annual risk for VTE as high risk and those at less than 5% annual risk for VTE as low risk, while recognizing that individual patient considerations may be more important than this stratification.

The risk for postoperative VTE associated with a particular procedure is not equivalent to the risk for thromboembolism associated with interruption of antithrombotic therapy, as the potential risk for arterial thrombosis as well as VTE must be considered when coumarins and antiplatelet medications are withheld.

Procedures associated with the highest risk for bleeding when perioperative anticoagulants/antithrombotics are used include urologic procedures; placement of pacemakers and implantable cardioverter defibrillators; endoscopic polypectomy (especially large sessile polyps); procedures on large vascular organs such as the liver, kidney, or spleen; bowel resections, cardiac surgery, major surgeries with tissue injury including joint replacements, cancer surgery, and reconstructive procedures; and intracranial/spinal surgeries.

While not evaluated in randomized trials, a standardized approach to perioperative anticoagulation is recommended in an effort to optimize patient outcomes. Suggestions include perioperative risk assessment at least 7 days prior to the procedure; patient/caregiver education; and medication calendars to optimize compliance; international normalized ratio (INR) measurement 1 day before surgery in patients requiring vitamin K antagonist (VKA) cessation; and routine assessment of postoperative hemostasis before resuming anticoagulants.

Implementation

When vitamin K antagonists must be withheld preoperatively, a 5-day hold interval is recommended. VKA may be resumed when adequate hemostasis is observed at 12-24 hours following the procedure.

Perioperative bridge anticoagulation is recommended in patients with mechanical valves, atrial fibrillation, and/or those with prior VTE whom are at high risk for thromboembolism.

An assessment of risk vs. benefit should be used to decide whether to implement bridge anticoagulation in patients with an intermediate 5%-10%/year risk for recurrent VTE. This assessment should incorporate the procedural risk for perioperative bleeding.

No bridging anticoagulation is recommended in patients at low risk, less than 5% recurrent VTE risk annually.

Patients requiring minor dental procedures at moderate risk of bleeding whom are chronically treated with VKA may have the VKA continued through the perioperative period and be treated with prohemostatic agents for bleeding prevention; alternatively, VKA may be held 2-3 days prior to the procedure and resumed afterward.

Patients who are receiving VKA treatment should have this continued through the perioperative period for minor dermatologic procedures and cataract surgery.

Patients who receive bridging anticoagulation with intravenous unfractionated heparin should have the heparin stopped 4-6 hours prior to the procedure. Patients receiving subcutaneous low-molecular weight heparin should receive their last preoperative dose 24 hours prior to the procedure. For procedures with a high bleeding risk, demonstrated hemostasis, and a 48-72 hour interval should elapse prior to resuming low-molecular weight heparin; a 24-hour interval is reasonable for procedures at lower bleeding risk.

Patients who are receiving aspirin for secondary cardiovascular prevention should have aspirin continued through the perioperative period for minor dental procedures, minor dermatologic procedures, or cataract surgery.

If possible, it is recommended that surgery and procedures be deferred for at least 6 weeks following implantation of bare-metal coronary stents and for at least 6 months following implantation of drug-eluting coronary stents. If it is not possible to defer procedures, it is recommended that dual antiplatelet medications be continued through the perioperative period. These patients are expected to have increased perioperative bleeding and must be monitored closely.

Patients who are treated with aspirin and whom are at moderate or greater risk for cardiovascular events should have aspirin continued through the perioperative period to aid in reduction of perioperative CV risk.

Aspirin should be continued through the perioperative period in patients with coronary artery disease requiring CABG. Clopidogrel should be stopped 5 days preoperatively and aspirin should be continued in patients previously treated with dual antiplatelet therapy who require CABG.

Reference

Douketis JD, et al., Perioperative Management of Antithrombotic Therapy in Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141 (2)(Suppl);e326S-350S.

William E. Golden, M.D., is professor of medicine and public health, and Robert H. Hopkins, M.D., is program director for the internal medicine/pediatrics combined residency program, both at the University of Arkansas, Little Rock. Write to them at imnews@elsevier.com. They reported having no conflicts of interest.

Health Affairs has published a study that demonstrates little impact of Medicare’s mortality data on improving outcomes. No surprise here. Once again, we learn that data without context have modest motivational effects. While the data imply an urgent message, too often the response generates two questions that lack obvious answers: “So what?” and “Now what?”

What are the limitations of mortality data? All-cause mortality can contaminate the picture pertaining to a particular disease state or procedure, particularly in populations who are of advanced age, poor socioeconomic status, or limited health literacy. The complexities of adherence, care coordination, social support, and comorbidities result in a multivariable equation that can defy root cause analysis for a population that is not homogeneous.

While many process measures are unsatisfying, judicious linking of evidence-based care activities to outcomes provides end users a framework to design one or several interventions that can improve the broader metric, such as mortality. Clearly, any effort to improve mortality requires identification of components of care that should have priority attention to effect change. Progress tracked on sub metrics is more immediate and gives reassurance on eventual success or suggests need for further thought on effective improvement strategies to address the outcome of concern.

Focus on all-cause mortality and 30-day readmission rates presents a “Back to the Future” moment. Papers written in the early 90’s used Monte Carlo modeling to demonstrate the limited predictive value of readmission events in chronic disease. Twenty years later, on the eve of pay-for-performance penalties for heart failure, papers demonstrate limited change in global readmission rates, despite hospital QI initiatives. “Compelling data” do not always suggest solutions based on their existence alone

Clearly, mortality and readmission rates can improve, but mostly at the margins. Data should promote creative thought. However, without a breakout conceptual leap in processes, outcomes will remain the same and we’ll still be in need of a broad-based strategy for change.

Health Affairs has published a study that demonstrates little impact of Medicare’s mortality data on improving outcomes. No surprise here. Once again, we learn that data without context have modest motivational effects. While the data imply an urgent message, too often the response generates two questions that lack obvious answers: “So what?” and “Now what?”

What are the limitations of mortality data? All-cause mortality can contaminate the picture pertaining to a particular disease state or procedure, particularly in populations who are of advanced age, poor socioeconomic status, or limited health literacy. The complexities of adherence, care coordination, social support, and comorbidities result in a multivariable equation that can defy root cause analysis for a population that is not homogeneous.

While many process measures are unsatisfying, judicious linking of evidence-based care activities to outcomes provides end users a framework to design one or several interventions that can improve the broader metric, such as mortality. Clearly, any effort to improve mortality requires identification of components of care that should have priority attention to effect change. Progress tracked on sub metrics is more immediate and gives reassurance on eventual success or suggests need for further thought on effective improvement strategies to address the outcome of concern.

Focus on all-cause mortality and 30-day readmission rates presents a “Back to the Future” moment. Papers written in the early 90’s used Monte Carlo modeling to demonstrate the limited predictive value of readmission events in chronic disease. Twenty years later, on the eve of pay-for-performance penalties for heart failure, papers demonstrate limited change in global readmission rates, despite hospital QI initiatives. “Compelling data” do not always suggest solutions based on their existence alone

Clearly, mortality and readmission rates can improve, but mostly at the margins. Data should promote creative thought. However, without a breakout conceptual leap in processes, outcomes will remain the same and we’ll still be in need of a broad-based strategy for change.

Health Affairs has published a study that demonstrates little impact of Medicare’s mortality data on improving outcomes. No surprise here. Once again, we learn that data without context have modest motivational effects. While the data imply an urgent message, too often the response generates two questions that lack obvious answers: “So what?” and “Now what?”

What are the limitations of mortality data? All-cause mortality can contaminate the picture pertaining to a particular disease state or procedure, particularly in populations who are of advanced age, poor socioeconomic status, or limited health literacy. The complexities of adherence, care coordination, social support, and comorbidities result in a multivariable equation that can defy root cause analysis for a population that is not homogeneous.

While many process measures are unsatisfying, judicious linking of evidence-based care activities to outcomes provides end users a framework to design one or several interventions that can improve the broader metric, such as mortality. Clearly, any effort to improve mortality requires identification of components of care that should have priority attention to effect change. Progress tracked on sub metrics is more immediate and gives reassurance on eventual success or suggests need for further thought on effective improvement strategies to address the outcome of concern.

Focus on all-cause mortality and 30-day readmission rates presents a “Back to the Future” moment. Papers written in the early 90’s used Monte Carlo modeling to demonstrate the limited predictive value of readmission events in chronic disease. Twenty years later, on the eve of pay-for-performance penalties for heart failure, papers demonstrate limited change in global readmission rates, despite hospital QI initiatives. “Compelling data” do not always suggest solutions based on their existence alone

Clearly, mortality and readmission rates can improve, but mostly at the margins. Data should promote creative thought. However, without a breakout conceptual leap in processes, outcomes will remain the same and we’ll still be in need of a broad-based strategy for change.

Background

Hypertension affects most people older than age 65 years. The American College of Cardiology, in collaboration with several partner organizations, issued an expert consensus document on the evaluation and treatment of hypertension in seniors. The document provides consensus, rather than rigorous evidence-based guidance. Most clinical trials of hypertension treatments are based on studies with few or no older patients, or without age-specific analyses.

Conclusions

Age-related changes in vascular stiffness, atherosclerotic disease, autonomic dysregulation, and age-related declines in renal function all are implicated in the greater incidence of hypertension in seniors, compared with a younger population.

The recommended treatment target for uncomplicated hypertension in seniors is less than 140/90 mm Hg, based on expert opinion. The systolic BP target in persons over age 80 years should be 140-145 mm Hg, if tolerated. Lower BP targets recommended in other guidelines for patients with diabetes, chronic kidney disease with proteinuria, and systolic heart failure are endorsed.

Older patients are more prone to hyperkalemia than younger hypertensive adults.

Serum uric acid independently predicts cardiovascular events in older hypertensive patients.

Secondary hypertension from renal artery stenosis, obstructive sleep apnea, endocrinopathies, medications, and lifestyle issues are important considerations in elderly adults, particularly those with resistant hypertension.

Treatment-resistant hypertension is more common with advancing age and increasing duration of hypertension.

Pseudohypertension and white coat hypertension are more common in the elderly although the prevalence is not well quantified.

Hypertension pharmacotherapy is generally recommended in seniors with the caveat that there are more limited data in patients over age 80 years. Most elderly patients will need more than two medications to reach blood pressure goals.

Implementation

The diagnosis of hypertension should be based on at least three high-quality blood pressure readings obtained on two or more visits; blood pressure should be measured when the patient is in a well-supported seated position after a 5 minute rest.

A complete history and examination, electrocardiogram, and basic laboratory evaluation (urinalysis, blood chemistries with estimated glomerular filtration rate, fasting glucose, and fasting lipid profile) are suggested in the initial evaluation of hypertension in the elderly. Select patients may warrant additional initial testing.

Lifestyle changes including smoking cessation, moderation of alcohol and sodium intake, weight reduction, and increased physical activity are recommended and might be sufficient to reduce blood pressure to goal in mildly hypertensive seniors.

Antihypertensive medications should be initiated at the lowest dose and increased gradually to the maximum dose until the treatment target is reached. If the goal is not achieved or the drug is not tolerated, a second agent from a different class should be added (or substituted). Elderly patients with blood pressures greater than 20/10 mm Hg over goal usually require initiation of two medications.

A thiazide diuretic should be the first or second antihypertensive medication initiated in most seniors.

Beta-blockers should generally be reserved for combination therapy and/or treatment of patients with other specific indications for this medication class (for example, coronary artery disease, angina, or heart failure).

Alpha-blockers should not be considered first-line antihypertensives in elderly adults.

Calcium antagonists, with the exception of short-acting dihydropyridines, can be useful first-line antihypertensives or as part of combination regimens in seniors.

ACE inhibitors are useful; however, they may precipitate chronic cough or, less commonly, angioedema and rash. ACE inhibitors or angiotensin-receptor blockers should be components of the hypertension regimen in elderly patients with diabetes and heart failure.

Direct renin inhibitors have been demonstrated to be effective in combination with a thiazide, calcium antagonist, or ACE inhibitor in patients older than age 75 years.

Hydralazine and minoxidil should only be used as late additions to combination regimens in elderly patients with resistant hypertension, because of their numerous adverse effects.

Pseudohypertension should be suspected in older patients with refractory hypertension, a lack of end-organ damage or symptoms of overmedication.

Home blood pressure measurement can be very helpful in the elderly. Ambulatory blood pressure monitoring is suggested to confirm a diagnosis of white coat hypertension, when the response to medication is unclear from office measurements, and to evaluate potential symptoms of orthostasis.

Polypharmacy, drug interactions, nonadherence, and quality of life issues can be important in the development of a management plan for elderly hypertensive patients, particularly as seniors average six or more medications for chronic conditions. Multidisciplinary teams may be particularly useful in meeting the needs of this growing patient population.

Reference

Aronow, WS, et al. "ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension," published online April 25 (J. Am. Coll. Cardiol. 2011;57 [doi:10.1016/j.jacc.2011.01.008]).

Background

Hypertension affects most people older than age 65 years. The American College of Cardiology, in collaboration with several partner organizations, issued an expert consensus document on the evaluation and treatment of hypertension in seniors. The document provides consensus, rather than rigorous evidence-based guidance. Most clinical trials of hypertension treatments are based on studies with few or no older patients, or without age-specific analyses.

Conclusions

Age-related changes in vascular stiffness, atherosclerotic disease, autonomic dysregulation, and age-related declines in renal function all are implicated in the greater incidence of hypertension in seniors, compared with a younger population.

The recommended treatment target for uncomplicated hypertension in seniors is less than 140/90 mm Hg, based on expert opinion. The systolic BP target in persons over age 80 years should be 140-145 mm Hg, if tolerated. Lower BP targets recommended in other guidelines for patients with diabetes, chronic kidney disease with proteinuria, and systolic heart failure are endorsed.

Older patients are more prone to hyperkalemia than younger hypertensive adults.

Serum uric acid independently predicts cardiovascular events in older hypertensive patients.

Secondary hypertension from renal artery stenosis, obstructive sleep apnea, endocrinopathies, medications, and lifestyle issues are important considerations in elderly adults, particularly those with resistant hypertension.

Treatment-resistant hypertension is more common with advancing age and increasing duration of hypertension.

Pseudohypertension and white coat hypertension are more common in the elderly although the prevalence is not well quantified.

Hypertension pharmacotherapy is generally recommended in seniors with the caveat that there are more limited data in patients over age 80 years. Most elderly patients will need more than two medications to reach blood pressure goals.

Implementation

The diagnosis of hypertension should be based on at least three high-quality blood pressure readings obtained on two or more visits; blood pressure should be measured when the patient is in a well-supported seated position after a 5 minute rest.

A complete history and examination, electrocardiogram, and basic laboratory evaluation (urinalysis, blood chemistries with estimated glomerular filtration rate, fasting glucose, and fasting lipid profile) are suggested in the initial evaluation of hypertension in the elderly. Select patients may warrant additional initial testing.

Lifestyle changes including smoking cessation, moderation of alcohol and sodium intake, weight reduction, and increased physical activity are recommended and might be sufficient to reduce blood pressure to goal in mildly hypertensive seniors.

Antihypertensive medications should be initiated at the lowest dose and increased gradually to the maximum dose until the treatment target is reached. If the goal is not achieved or the drug is not tolerated, a second agent from a different class should be added (or substituted). Elderly patients with blood pressures greater than 20/10 mm Hg over goal usually require initiation of two medications.

A thiazide diuretic should be the first or second antihypertensive medication initiated in most seniors.

Beta-blockers should generally be reserved for combination therapy and/or treatment of patients with other specific indications for this medication class (for example, coronary artery disease, angina, or heart failure).

Alpha-blockers should not be considered first-line antihypertensives in elderly adults.

Calcium antagonists, with the exception of short-acting dihydropyridines, can be useful first-line antihypertensives or as part of combination regimens in seniors.

ACE inhibitors are useful; however, they may precipitate chronic cough or, less commonly, angioedema and rash. ACE inhibitors or angiotensin-receptor blockers should be components of the hypertension regimen in elderly patients with diabetes and heart failure.

Direct renin inhibitors have been demonstrated to be effective in combination with a thiazide, calcium antagonist, or ACE inhibitor in patients older than age 75 years.

Hydralazine and minoxidil should only be used as late additions to combination regimens in elderly patients with resistant hypertension, because of their numerous adverse effects.

Pseudohypertension should be suspected in older patients with refractory hypertension, a lack of end-organ damage or symptoms of overmedication.

Home blood pressure measurement can be very helpful in the elderly. Ambulatory blood pressure monitoring is suggested to confirm a diagnosis of white coat hypertension, when the response to medication is unclear from office measurements, and to evaluate potential symptoms of orthostasis.

Polypharmacy, drug interactions, nonadherence, and quality of life issues can be important in the development of a management plan for elderly hypertensive patients, particularly as seniors average six or more medications for chronic conditions. Multidisciplinary teams may be particularly useful in meeting the needs of this growing patient population.

Reference

Aronow, WS, et al. "ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension," published online April 25 (J. Am. Coll. Cardiol. 2011;57 [doi:10.1016/j.jacc.2011.01.008]).

Background

Hypertension affects most people older than age 65 years. The American College of Cardiology, in collaboration with several partner organizations, issued an expert consensus document on the evaluation and treatment of hypertension in seniors. The document provides consensus, rather than rigorous evidence-based guidance. Most clinical trials of hypertension treatments are based on studies with few or no older patients, or without age-specific analyses.

Conclusions

Age-related changes in vascular stiffness, atherosclerotic disease, autonomic dysregulation, and age-related declines in renal function all are implicated in the greater incidence of hypertension in seniors, compared with a younger population.

The recommended treatment target for uncomplicated hypertension in seniors is less than 140/90 mm Hg, based on expert opinion. The systolic BP target in persons over age 80 years should be 140-145 mm Hg, if tolerated. Lower BP targets recommended in other guidelines for patients with diabetes, chronic kidney disease with proteinuria, and systolic heart failure are endorsed.

Older patients are more prone to hyperkalemia than younger hypertensive adults.

Serum uric acid independently predicts cardiovascular events in older hypertensive patients.

Secondary hypertension from renal artery stenosis, obstructive sleep apnea, endocrinopathies, medications, and lifestyle issues are important considerations in elderly adults, particularly those with resistant hypertension.

Treatment-resistant hypertension is more common with advancing age and increasing duration of hypertension.

Pseudohypertension and white coat hypertension are more common in the elderly although the prevalence is not well quantified.

Hypertension pharmacotherapy is generally recommended in seniors with the caveat that there are more limited data in patients over age 80 years. Most elderly patients will need more than two medications to reach blood pressure goals.

Implementation

The diagnosis of hypertension should be based on at least three high-quality blood pressure readings obtained on two or more visits; blood pressure should be measured when the patient is in a well-supported seated position after a 5 minute rest.

A complete history and examination, electrocardiogram, and basic laboratory evaluation (urinalysis, blood chemistries with estimated glomerular filtration rate, fasting glucose, and fasting lipid profile) are suggested in the initial evaluation of hypertension in the elderly. Select patients may warrant additional initial testing.

Lifestyle changes including smoking cessation, moderation of alcohol and sodium intake, weight reduction, and increased physical activity are recommended and might be sufficient to reduce blood pressure to goal in mildly hypertensive seniors.

Antihypertensive medications should be initiated at the lowest dose and increased gradually to the maximum dose until the treatment target is reached. If the goal is not achieved or the drug is not tolerated, a second agent from a different class should be added (or substituted). Elderly patients with blood pressures greater than 20/10 mm Hg over goal usually require initiation of two medications.

A thiazide diuretic should be the first or second antihypertensive medication initiated in most seniors.

Beta-blockers should generally be reserved for combination therapy and/or treatment of patients with other specific indications for this medication class (for example, coronary artery disease, angina, or heart failure).

Alpha-blockers should not be considered first-line antihypertensives in elderly adults.

Calcium antagonists, with the exception of short-acting dihydropyridines, can be useful first-line antihypertensives or as part of combination regimens in seniors.

ACE inhibitors are useful; however, they may precipitate chronic cough or, less commonly, angioedema and rash. ACE inhibitors or angiotensin-receptor blockers should be components of the hypertension regimen in elderly patients with diabetes and heart failure.

Direct renin inhibitors have been demonstrated to be effective in combination with a thiazide, calcium antagonist, or ACE inhibitor in patients older than age 75 years.

Hydralazine and minoxidil should only be used as late additions to combination regimens in elderly patients with resistant hypertension, because of their numerous adverse effects.

Pseudohypertension should be suspected in older patients with refractory hypertension, a lack of end-organ damage or symptoms of overmedication.

Home blood pressure measurement can be very helpful in the elderly. Ambulatory blood pressure monitoring is suggested to confirm a diagnosis of white coat hypertension, when the response to medication is unclear from office measurements, and to evaluate potential symptoms of orthostasis.

Polypharmacy, drug interactions, nonadherence, and quality of life issues can be important in the development of a management plan for elderly hypertensive patients, particularly as seniors average six or more medications for chronic conditions. Multidisciplinary teams may be particularly useful in meeting the needs of this growing patient population.

Reference

Aronow, WS, et al. "ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension," published online April 25 (J. Am. Coll. Cardiol. 2011;57 [doi:10.1016/j.jacc.2011.01.008]).

Background

Hypertension affects most people older than age 65 years. The American College of Cardiology, in collaboration with several partner organizations, issued an expert consensus document on the evaluation and treatment of hypertension in seniors. The document provides consensus, rather than rigorous evidence-based guidance. Most clinical trials of hypertension treatments are based on studies with few or no older patients, or without age-specific analyses.

Conclusions

Age-related changes in vascular stiffness, atherosclerotic disease, autonomic dysregulation, and age-related declines in renal function all are implicated in the greater incidence of hypertension in seniors, compared with a younger population.

The recommended treatment target for uncomplicated hypertension in seniors is less than 140/90 mm Hg, based on expert opinion. The systolic BP target in persons over age 80 years should be 140-145 mm Hg, if tolerated. Lower BP targets recommended in other guidelines for patients with diabetes, chronic kidney disease with proteinuria, and systolic heart failure are endorsed.

Older patients are more prone to hyperkalemia than younger hypertensive adults.

Serum uric acid independently predicts cardiovascular events in older hypertensive patients.

Secondary hypertension from renal artery stenosis, obstructive sleep apnea, endocrinopathies, medications, and lifestyle issues are important considerations in elderly adults, particularly those with resistant hypertension.

Treatment-resistant hypertension is more common with advancing age and increasing duration of hypertension.

Pseudohypertension and white coat hypertension are more common in the elderly although the prevalence is not well quantified.

Hypertension pharmacotherapy is generally recommended in seniors with the caveat that there are more limited data in patients over age 80 years. Most elderly patients will need more than two medications to reach blood pressure goals.

Implementation

The diagnosis of hypertension should be based on at least three high-quality blood pressure readings obtained on two or more visits; blood pressure should be measured when the patient is in a well-supported seated position after a 5 minute rest.

A complete history and examination, electrocardiogram, and basic laboratory evaluation (urinalysis, blood chemistries with estimated glomerular filtration rate, fasting glucose, and fasting lipid profile) are suggested in the initial evaluation of hypertension in the elderly. Select patients may warrant additional initial testing.

Lifestyle changes including smoking cessation, moderation of alcohol and sodium intake, weight reduction, and increased physical activity are recommended and might be sufficient to reduce blood pressure to goal in mildly hypertensive seniors.

Antihypertensive medications should be initiated at the lowest dose and increased gradually to the maximum dose until the treatment target is reached. If the goal is not achieved or the drug is not tolerated, a second agent from a different class should be added (or substituted). Elderly patients with blood pressures greater than 20/10 mm Hg over goal usually require initiation of two medications.

A thiazide diuretic should be the first or second antihypertensive medication initiated in most seniors.

Beta-blockers should generally be reserved for combination therapy and/or treatment of patients with other specific indications for this medication class (for example, coronary artery disease, angina, or heart failure).

Alpha-blockers should not be considered first-line antihypertensives in elderly adults.

Calcium antagonists, with the exception of short-acting dihydropyridines, can be useful first-line antihypertensives or as part of combination regimens in seniors.

ACE inhibitors are useful; however, they may precipitate chronic cough or, less commonly, angioedema and rash. ACE inhibitors or angiotensin-receptor blockers should be components of the hypertension regimen in elderly patients with diabetes and heart failure.

Direct renin inhibitors have been demonstrated to be effective in combination with a thiazide, calcium antagonist, or ACE inhibitor in patients older than age 75 years.

Hydralazine and minoxidil should only be used as late additions to combination regimens in elderly patients with resistant hypertension, because of their numerous adverse effects.

Pseudohypertension should be suspected in older patients with refractory hypertension, a lack of end-organ damage or symptoms of overmedication.

Home blood pressure measurement can be very helpful in the elderly. Ambulatory blood pressure monitoring is suggested to confirm a diagnosis of white coat hypertension, when the response to medication is unclear from office measurements, and to evaluate potential symptoms of orthostasis.

Polypharmacy, drug interactions, nonadherence, and quality of life issues can be important in the development of a management plan for elderly hypertensive patients, particularly as seniors average six or more medications for chronic conditions. Multidisciplinary teams may be particularly useful in meeting the needs of this growing patient population.

Reference

Aronow, WS, et al. "ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension," published online April 25 (J. Am. Coll. Cardiol. 2011;57 [doi:10.1016/j.jacc.2011.01.008]).

Background

Hypertension affects most people older than age 65 years. The American College of Cardiology, in collaboration with several partner organizations, issued an expert consensus document on the evaluation and treatment of hypertension in seniors. The document provides consensus, rather than rigorous evidence-based guidance. Most clinical trials of hypertension treatments are based on studies with few or no older patients, or without age-specific analyses.

Conclusions

Age-related changes in vascular stiffness, atherosclerotic disease, autonomic dysregulation, and age-related declines in renal function all are implicated in the greater incidence of hypertension in seniors, compared with a younger population.

The recommended treatment target for uncomplicated hypertension in seniors is less than 140/90 mm Hg, based on expert opinion. The systolic BP target in persons over age 80 years should be 140-145 mm Hg, if tolerated. Lower BP targets recommended in other guidelines for patients with diabetes, chronic kidney disease with proteinuria, and systolic heart failure are endorsed.

Older patients are more prone to hyperkalemia than younger hypertensive adults.

Serum uric acid independently predicts cardiovascular events in older hypertensive patients.

Secondary hypertension from renal artery stenosis, obstructive sleep apnea, endocrinopathies, medications, and lifestyle issues are important considerations in elderly adults, particularly those with resistant hypertension.

Treatment-resistant hypertension is more common with advancing age and increasing duration of hypertension.

Pseudohypertension and white coat hypertension are more common in the elderly although the prevalence is not well quantified.

Hypertension pharmacotherapy is generally recommended in seniors with the caveat that there are more limited data in patients over age 80 years. Most elderly patients will need more than two medications to reach blood pressure goals.

Implementation

The diagnosis of hypertension should be based on at least three high-quality blood pressure readings obtained on two or more visits; blood pressure should be measured when the patient is in a well-supported seated position after a 5 minute rest.

A complete history and examination, electrocardiogram, and basic laboratory evaluation (urinalysis, blood chemistries with estimated glomerular filtration rate, fasting glucose, and fasting lipid profile) are suggested in the initial evaluation of hypertension in the elderly. Select patients may warrant additional initial testing.

Lifestyle changes including smoking cessation, moderation of alcohol and sodium intake, weight reduction, and increased physical activity are recommended and might be sufficient to reduce blood pressure to goal in mildly hypertensive seniors.

Antihypertensive medications should be initiated at the lowest dose and increased gradually to the maximum dose until the treatment target is reached. If the goal is not achieved or the drug is not tolerated, a second agent from a different class should be added (or substituted). Elderly patients with blood pressures greater than 20/10 mm Hg over goal usually require initiation of two medications.

A thiazide diuretic should be the first or second antihypertensive medication initiated in most seniors.

Beta-blockers should generally be reserved for combination therapy and/or treatment of patients with other specific indications for this medication class (for example, coronary artery disease, angina, or heart failure).

Alpha-blockers should not be considered first-line antihypertensives in elderly adults.

Calcium antagonists, with the exception of short-acting dihydropyridines, can be useful first-line antihypertensives or as part of combination regimens in seniors.

ACE inhibitors are useful; however, they may precipitate chronic cough or, less commonly, angioedema and rash. ACE inhibitors or angiotensin-receptor blockers should be components of the hypertension regimen in elderly patients with diabetes and heart failure.

Direct renin inhibitors have been demonstrated to be effective in combination with a thiazide, calcium antagonist, or ACE inhibitor in patients older than age 75 years.

Hydralazine and minoxidil should only be used as late additions to combination regimens in elderly patients with resistant hypertension, because of their numerous adverse effects.

Pseudohypertension should be suspected in older patients with refractory hypertension, a lack of end-organ damage or symptoms of overmedication.

Home blood pressure measurement can be very helpful in the elderly. Ambulatory blood pressure monitoring is suggested to confirm a diagnosis of white coat hypertension, when the response to medication is unclear from office measurements, and to evaluate potential symptoms of orthostasis.

Polypharmacy, drug interactions, nonadherence, and quality of life issues can be important in the development of a management plan for elderly hypertensive patients, particularly as seniors average six or more medications for chronic conditions. Multidisciplinary teams may be particularly useful in meeting the needs of this growing patient population.

Reference

Aronow, WS, et al. "ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension," published online April 25 (J. Am. Coll. Cardiol. 2011;57 [doi:10.1016/j.jacc.2011.01.008]).

Background

Hypertension affects most people older than age 65 years. The American College of Cardiology, in collaboration with several partner organizations, issued an expert consensus document on the evaluation and treatment of hypertension in seniors. The document provides consensus, rather than rigorous evidence-based guidance. Most clinical trials of hypertension treatments are based on studies with few or no older patients, or without age-specific analyses.

Conclusions

Age-related changes in vascular stiffness, atherosclerotic disease, autonomic dysregulation, and age-related declines in renal function all are implicated in the greater incidence of hypertension in seniors, compared with a younger population.

The recommended treatment target for uncomplicated hypertension in seniors is less than 140/90 mm Hg, based on expert opinion. The systolic BP target in persons over age 80 years should be 140-145 mm Hg, if tolerated. Lower BP targets recommended in other guidelines for patients with diabetes, chronic kidney disease with proteinuria, and systolic heart failure are endorsed.

Older patients are more prone to hyperkalemia than younger hypertensive adults.

Serum uric acid independently predicts cardiovascular events in older hypertensive patients.

Secondary hypertension from renal artery stenosis, obstructive sleep apnea, endocrinopathies, medications, and lifestyle issues are important considerations in elderly adults, particularly those with resistant hypertension.

Treatment-resistant hypertension is more common with advancing age and increasing duration of hypertension.

Pseudohypertension and white coat hypertension are more common in the elderly although the prevalence is not well quantified.

Hypertension pharmacotherapy is generally recommended in seniors with the caveat that there are more limited data in patients over age 80 years. Most elderly patients will need more than two medications to reach blood pressure goals.

Implementation

The diagnosis of hypertension should be based on at least three high-quality blood pressure readings obtained on two or more visits; blood pressure should be measured when the patient is in a well-supported seated position after a 5 minute rest.

A complete history and examination, electrocardiogram, and basic laboratory evaluation (urinalysis, blood chemistries with estimated glomerular filtration rate, fasting glucose, and fasting lipid profile) are suggested in the initial evaluation of hypertension in the elderly. Select patients may warrant additional initial testing.

Lifestyle changes including smoking cessation, moderation of alcohol and sodium intake, weight reduction, and increased physical activity are recommended and might be sufficient to reduce blood pressure to goal in mildly hypertensive seniors.

Antihypertensive medications should be initiated at the lowest dose and increased gradually to the maximum dose until the treatment target is reached. If the goal is not achieved or the drug is not tolerated, a second agent from a different class should be added (or substituted). Elderly patients with blood pressures greater than 20/10 mm Hg over goal usually require initiation of two medications.

A thiazide diuretic should be the first or second antihypertensive medication initiated in most seniors.

Beta-blockers should generally be reserved for combination therapy and/or treatment of patients with other specific indications for this medication class (for example, coronary artery disease, angina, or heart failure).

Alpha-blockers should not be considered first-line antihypertensives in elderly adults.

Calcium antagonists, with the exception of short-acting dihydropyridines, can be useful first-line antihypertensives or as part of combination regimens in seniors.

ACE inhibitors are useful; however, they may precipitate chronic cough or, less commonly, angioedema and rash. ACE inhibitors or angiotensin-receptor blockers should be components of the hypertension regimen in elderly patients with diabetes and heart failure.

Direct renin inhibitors have been demonstrated to be effective in combination with a thiazide, calcium antagonist, or ACE inhibitor in patients older than age 75 years.

Hydralazine and minoxidil should only be used as late additions to combination regimens in elderly patients with resistant hypertension, because of their numerous adverse effects.

Pseudohypertension should be suspected in older patients with refractory hypertension, a lack of end-organ damage or symptoms of overmedication.

Home blood pressure measurement can be very helpful in the elderly. Ambulatory blood pressure monitoring is suggested to confirm a diagnosis of white coat hypertension, when the response to medication is unclear from office measurements, and to evaluate potential symptoms of orthostasis.

Polypharmacy, drug interactions, nonadherence, and quality of life issues can be important in the development of a management plan for elderly hypertensive patients, particularly as seniors average six or more medications for chronic conditions. Multidisciplinary teams may be particularly useful in meeting the needs of this growing patient population.

Reference

Aronow, WS, et al. "ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension," published online April 25 (J. Am. Coll. Cardiol. 2011;57 [doi:10.1016/j.jacc.2011.01.008]).

Background

Hypertension affects most people older than age 65 years. The American College of Cardiology, in collaboration with several partner organizations, issued an expert consensus document on the evaluation and treatment of hypertension in seniors. The document provides consensus, rather than rigorous evidence-based guidance. Most clinical trials of hypertension treatments are based on studies with few or no older patients, or without age-specific analyses.

Conclusions

Age-related changes in vascular stiffness, atherosclerotic disease, autonomic dysregulation, and age-related declines in renal function all are implicated in the greater incidence of hypertension in seniors, compared with a younger population.

The recommended treatment target for uncomplicated hypertension in seniors is less than 140/90 mm Hg, based on expert opinion. The systolic BP target in persons over age 80 years should be 140-145 mm Hg, if tolerated. Lower BP targets recommended in other guidelines for patients with diabetes, chronic kidney disease with proteinuria, and systolic heart failure are endorsed.

Older patients are more prone to hyperkalemia than younger hypertensive adults.

Serum uric acid independently predicts cardiovascular events in older hypertensive patients.

Secondary hypertension from renal artery stenosis, obstructive sleep apnea, endocrinopathies, medications, and lifestyle issues are important considerations in elderly adults, particularly those with resistant hypertension.

Treatment-resistant hypertension is more common with advancing age and increasing duration of hypertension.

Pseudohypertension and white coat hypertension are more common in the elderly although the prevalence is not well quantified.

Hypertension pharmacotherapy is generally recommended in seniors with the caveat that there are more limited data in patients over age 80 years. Most elderly patients will need more than two medications to reach blood pressure goals.

Implementation

The diagnosis of hypertension should be based on at least three high-quality blood pressure readings obtained on two or more visits; blood pressure should be measured when the patient is in a well-supported seated position after a 5 minute rest.

A complete history and examination, electrocardiogram, and basic laboratory evaluation (urinalysis, blood chemistries with estimated glomerular filtration rate, fasting glucose, and fasting lipid profile) are suggested in the initial evaluation of hypertension in the elderly. Select patients may warrant additional initial testing.

Lifestyle changes including smoking cessation, moderation of alcohol and sodium intake, weight reduction, and increased physical activity are recommended and might be sufficient to reduce blood pressure to goal in mildly hypertensive seniors.

Antihypertensive medications should be initiated at the lowest dose and increased gradually to the maximum dose until the treatment target is reached. If the goal is not achieved or the drug is not tolerated, a second agent from a different class should be added (or substituted). Elderly patients with blood pressures greater than 20/10 mm Hg over goal usually require initiation of two medications.

A thiazide diuretic should be the first or second antihypertensive medication initiated in most seniors.

Beta-blockers should generally be reserved for combination therapy and/or treatment of patients with other specific indications for this medication class (for example, coronary artery disease, angina, or heart failure).

Alpha-blockers should not be considered first-line antihypertensives in elderly adults.

Calcium antagonists, with the exception of short-acting dihydropyridines, can be useful first-line antihypertensives or as part of combination regimens in seniors.

ACE inhibitors are useful; however, they may precipitate chronic cough or, less commonly, angioedema and rash. ACE inhibitors or angiotensin-receptor blockers should be components of the hypertension regimen in elderly patients with diabetes and heart failure.

Direct renin inhibitors have been demonstrated to be effective in combination with a thiazide, calcium antagonist, or ACE inhibitor in patients older than age 75 years.

Hydralazine and minoxidil should only be used as late additions to combination regimens in elderly patients with resistant hypertension, because of their numerous adverse effects.

Pseudohypertension should be suspected in older patients with refractory hypertension, a lack of end-organ damage or symptoms of overmedication.

Home blood pressure measurement can be very helpful in the elderly. Ambulatory blood pressure monitoring is suggested to confirm a diagnosis of white coat hypertension, when the response to medication is unclear from office measurements, and to evaluate potential symptoms of orthostasis.

Polypharmacy, drug interactions, nonadherence, and quality of life issues can be important in the development of a management plan for elderly hypertensive patients, particularly as seniors average six or more medications for chronic conditions. Multidisciplinary teams may be particularly useful in meeting the needs of this growing patient population.

Reference

Aronow, WS, et al. "ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension," published online April 25 (J. Am. Coll. Cardiol. 2011;57 [doi:10.1016/j.jacc.2011.01.008]).

This column, "Effective Physician," appears regularly in Internal Medicine News, a publication of Elsevier. Dr. William E. Golden is professor of medicine and public health, and Dr. Robert H. Hopkins is program director for the internal medicine/pediatrics combined residency program at the University of Arkansas, Little Rock. Write to Dr. Golden and Dr. Hopkins. They reported having no conflicts of interest.

Background

Hypertension affects most people older than age 65 years. The American College of Cardiology, in collaboration with several partner organizations, issued an expert consensus document on the evaluation and treatment of hypertension in seniors. The document provides consensus, rather than rigorous evidence-based guidance. Most clinical trials of hypertension treatments are based on studies with few or no older patients, or without age-specific analyses.

Conclusions

Age-related changes in vascular stiffness, atherosclerotic disease, autonomic dysregulation, and age-related declines in renal function all are implicated in the greater incidence of hypertension in seniors, compared with a younger population.

The recommended treatment target for uncomplicated hypertension in seniors is less than 140/90 mm Hg, based on expert opinion. The systolic BP target in persons over age 80 years should be 140-145 mm Hg, if tolerated. Lower BP targets recommended in other guidelines for patients with diabetes, chronic kidney disease with proteinuria, and systolic heart failure are endorsed.

Older patients are more prone to hyperkalemia than younger hypertensive adults.

Serum uric acid independently predicts cardiovascular events in older hypertensive patients.

Secondary hypertension from renal artery stenosis, obstructive sleep apnea, endocrinopathies, medications, and lifestyle issues are important considerations in elderly adults, particularly those with resistant hypertension.

Treatment-resistant hypertension is more common with advancing age and increasing duration of hypertension.

Pseudohypertension and white coat hypertension are more common in the elderly although the prevalence is not well quantified.

Hypertension pharmacotherapy is generally recommended in seniors with the caveat that there are more limited data in patients over age 80 years. Most elderly patients will need more than two medications to reach blood pressure goals.

Implementation

The diagnosis of hypertension should be based on at least three high-quality blood pressure readings obtained on two or more visits; blood pressure should be measured when the patient is in a well-supported seated position after a 5 minute rest.

A complete history and examination, electrocardiogram, and basic laboratory evaluation (urinalysis, blood chemistries with estimated glomerular filtration rate, fasting glucose, and fasting lipid profile) are suggested in the initial evaluation of hypertension in the elderly. Select patients may warrant additional initial testing.

Lifestyle changes including smoking cessation, moderation of alcohol and sodium intake, weight reduction, and increased physical activity are recommended and might be sufficient to reduce blood pressure to goal in mildly hypertensive seniors.

Antihypertensive medications should be initiated at the lowest dose and increased gradually to the maximum dose until the treatment target is reached. If the goal is not achieved or the drug is not tolerated, a second agent from a different class should be added (or substituted). Elderly patients with blood pressures greater than 20/10 mm Hg over goal usually require initiation of two medications.

A thiazide diuretic should be the first or second antihypertensive medication initiated in most seniors.

Beta-blockers should generally be reserved for combination therapy and/or treatment of patients with other specific indications for this medication class (for example, coronary artery disease, angina, or heart failure).

Alpha-blockers should not be considered first-line antihypertensives in elderly adults.

Calcium antagonists, with the exception of short-acting dihydropyridines, can be useful first-line antihypertensives or as part of combination regimens in seniors.

ACE inhibitors are useful; however, they may precipitate chronic cough or, less commonly, angioedema and rash. ACE inhibitors or angiotensin-receptor blockers should be components of the hypertension regimen in elderly patients with diabetes and heart failure.

Direct renin inhibitors have been demonstrated to be effective in combination with a thiazide, calcium antagonist, or ACE inhibitor in patients older than age 75 years.

Hydralazine and minoxidil should only be used as late additions to combination regimens in elderly patients with resistant hypertension, because of their numerous adverse effects.

Pseudohypertension should be suspected in older patients with refractory hypertension, a lack of end-organ damage or symptoms of overmedication.

Home blood pressure measurement can be very helpful in the elderly. Ambulatory blood pressure monitoring is suggested to confirm a diagnosis of white coat hypertension, when the response to medication is unclear from office measurements, and to evaluate potential symptoms of orthostasis.

Polypharmacy, drug interactions, nonadherence, and quality of life issues can be important in the development of a management plan for elderly hypertensive patients, particularly as seniors average six or more medications for chronic conditions. Multidisciplinary teams may be particularly useful in meeting the needs of this growing patient population.

Reference

Aronow, WS, et al. "ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension," published online April 25 (J. Am. Coll. Cardiol. 2011;57 [doi:10.1016/j.jacc.2011.01.008]).

This column, "Effective Physician," appears regularly in Internal Medicine News, a publication of Elsevier. Dr. William E. Golden is professor of medicine and public health, and Dr. Robert H. Hopkins is program director for the internal medicine/pediatrics combined residency program at the University of Arkansas, Little Rock. Write to Dr. Golden and Dr. Hopkins. They reported having no conflicts of interest.

Background

Hypertension affects most people older than age 65 years. The American College of Cardiology, in collaboration with several partner organizations, issued an expert consensus document on the evaluation and treatment of hypertension in seniors. The document provides consensus, rather than rigorous evidence-based guidance. Most clinical trials of hypertension treatments are based on studies with few or no older patients, or without age-specific analyses.

Conclusions

Age-related changes in vascular stiffness, atherosclerotic disease, autonomic dysregulation, and age-related declines in renal function all are implicated in the greater incidence of hypertension in seniors, compared with a younger population.

The recommended treatment target for uncomplicated hypertension in seniors is less than 140/90 mm Hg, based on expert opinion. The systolic BP target in persons over age 80 years should be 140-145 mm Hg, if tolerated. Lower BP targets recommended in other guidelines for patients with diabetes, chronic kidney disease with proteinuria, and systolic heart failure are endorsed.

Older patients are more prone to hyperkalemia than younger hypertensive adults.

Serum uric acid independently predicts cardiovascular events in older hypertensive patients.

Secondary hypertension from renal artery stenosis, obstructive sleep apnea, endocrinopathies, medications, and lifestyle issues are important considerations in elderly adults, particularly those with resistant hypertension.

Treatment-resistant hypertension is more common with advancing age and increasing duration of hypertension.

Pseudohypertension and white coat hypertension are more common in the elderly although the prevalence is not well quantified.

Hypertension pharmacotherapy is generally recommended in seniors with the caveat that there are more limited data in patients over age 80 years. Most elderly patients will need more than two medications to reach blood pressure goals.

Implementation

The diagnosis of hypertension should be based on at least three high-quality blood pressure readings obtained on two or more visits; blood pressure should be measured when the patient is in a well-supported seated position after a 5 minute rest.

A complete history and examination, electrocardiogram, and basic laboratory evaluation (urinalysis, blood chemistries with estimated glomerular filtration rate, fasting glucose, and fasting lipid profile) are suggested in the initial evaluation of hypertension in the elderly. Select patients may warrant additional initial testing.

Lifestyle changes including smoking cessation, moderation of alcohol and sodium intake, weight reduction, and increased physical activity are recommended and might be sufficient to reduce blood pressure to goal in mildly hypertensive seniors.

Antihypertensive medications should be initiated at the lowest dose and increased gradually to the maximum dose until the treatment target is reached. If the goal is not achieved or the drug is not tolerated, a second agent from a different class should be added (or substituted). Elderly patients with blood pressures greater than 20/10 mm Hg over goal usually require initiation of two medications.

A thiazide diuretic should be the first or second antihypertensive medication initiated in most seniors.

Beta-blockers should generally be reserved for combination therapy and/or treatment of patients with other specific indications for this medication class (for example, coronary artery disease, angina, or heart failure).

Alpha-blockers should not be considered first-line antihypertensives in elderly adults.

Calcium antagonists, with the exception of short-acting dihydropyridines, can be useful first-line antihypertensives or as part of combination regimens in seniors.

ACE inhibitors are useful; however, they may precipitate chronic cough or, less commonly, angioedema and rash. ACE inhibitors or angiotensin-receptor blockers should be components of the hypertension regimen in elderly patients with diabetes and heart failure.

Direct renin inhibitors have been demonstrated to be effective in combination with a thiazide, calcium antagonist, or ACE inhibitor in patients older than age 75 years.

Hydralazine and minoxidil should only be used as late additions to combination regimens in elderly patients with resistant hypertension, because of their numerous adverse effects.

Pseudohypertension should be suspected in older patients with refractory hypertension, a lack of end-organ damage or symptoms of overmedication.

Home blood pressure measurement can be very helpful in the elderly. Ambulatory blood pressure monitoring is suggested to confirm a diagnosis of white coat hypertension, when the response to medication is unclear from office measurements, and to evaluate potential symptoms of orthostasis.

Polypharmacy, drug interactions, nonadherence, and quality of life issues can be important in the development of a management plan for elderly hypertensive patients, particularly as seniors average six or more medications for chronic conditions. Multidisciplinary teams may be particularly useful in meeting the needs of this growing patient population.

Reference

Aronow, WS, et al. "ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension," published online April 25 (J. Am. Coll. Cardiol. 2011;57 [doi:10.1016/j.jacc.2011.01.008]).

This column, "Effective Physician," appears regularly in Internal Medicine News, a publication of Elsevier. Dr. William E. Golden is professor of medicine and public health, and Dr. Robert H. Hopkins is program director for the internal medicine/pediatrics combined residency program at the University of Arkansas, Little Rock. Write to Dr. Golden and Dr. Hopkins. They reported having no conflicts of interest.

Breast cancer is the most common cancer in women the United States and affects nearly 200,000 individuals each year. More than half the cases occur in women aged over 65 years. On a positive note, 5-year survival now hovers around 90%.

While breast cancer is a heterogeneous disease, there are now more sophisticated risk models to identify patients with higher likelihood of developing the disease. Importantly, there are now reasonable interventions for high-risk women to reduce their incidence of breast cancer. Primary care offices should become familiar with risk assessment techniques and the potential value of chemopreventive strategies for high-risk women.

Many factors can increase the relative risk of development of breast cancer. Hormone replacement therapy, consumption of alcohol, menarche before age 12, late menopause, first childbirth after age 35, physical inactivity, and postmenopausal obesity modestly elevate the risk for the disease. Family history can have a substantial impact on risk. Having a first-degree relative with breast cancer increases one’s risk two- to fourfold. Personal histories of atypical hyperplasia or radiation therapy to the chest also elevate risk. Individuals with the BRCA mutation have up to an 80% increased risk of developing breast cancer over their lifetime.

Certain characteristics place patients at high risk for genetic predisposition for breast cancer. This can include a family history of cancer prior to 50 years of age; a family member with either breast cancer or breast and ovarian cancer; two close family members with breast, ovarian, or primary peritoneal cancers; or Ashkenazi Jewish ancestry.

Several mathematical models can calculate the risk for an individual patient and are available online. The Gail model is most widely used, especially for patients aged over 35 years. It can identify patients at high risk, which is defined as a 1.66% chance of developing breast cancer over the next 5 years.

Aside from greater surveillance and consideration of prophylactic mastectomy, chemoprevention is emerging as an important option for patients with higher likelihoods of developing breast cancer.

The National Surgical Adjuvant Breast and Bowel Project (NSABP) enrolled more than 13,000 women identified to be at high risk by the Gail model. Participants received tamoxifen or placebo and were followed for a median of 55 months. Overall, the risk reduction for invasive hormone receptor–positive cancer was 49% in the tamoxifen group. Certain subgroups, including women with atypical hyperplasia, had greater reductions in risk. There were other smaller studies that evaluated the same issue and showed variable (some nonstatistically significant) risk reduction in the tamoxifen groups. Study confounders include variations in use of hormone replacement therapy, in family history, and in prior hysterectomy status of study enrollees.

Overall, the benefit of tamoxifen between the four studies was a 38% reduction in the occurrence of hormone receptor–positive breast cancer (CI 8%-46%; P less than .001). Tamoxifen is used at 20 mg by mouth daily.

Of note, risk reduction was seen only in a hormone receptor–positive breast cancer, but not estrogen receptor–negative cancer. There are only limited data on the benefits of chemoprevention for women with BRCA mutations or a history of chest radiation.

Tamoxifen is a nonsteroidal mixed antagonist–agonist of the estrogen receptor. In breast tissue, tamoxifen blocks the binding of estrogen to tissue receptors. In other tissues such as bone and endometrium, however, tamoxifen is an estrogen agonist. While this is effective in reducing osteoclast activity and development of osteoporosis, it can lead to endometrial hyperplasia and subsequent adenocarcinoma. Other side effects include doubling the risk of deep venous thrombosis and an increased risk of cataract formation. In addition, tamoxifen interacts with SSRIs that can alter metabolism through the CYP2D6 pathway in the liver. This incomplete metabolism can promote increased rates of breast cancer recurrence in patients already receiving tamoxifen for established primary breast cancers. Paroxetine, fluoxetine, and sertraline are most prominently cited for this interaction.

Raloxifene is a selective reuptake estrogen modulator. Like tamoxifen, it can increase the risk for deep venous thrombosis but is associated with a lower risk for endometrial cancer.

Raloxifene trials for osteoporosis and cardiac disease were used to assess this agent for effectiveness in breast cancer chemoprevention. Raloxifene was used at 60 mg by mouth daily. Positive and encouraging findings have led to trials comparing raloxifene to tamoxifen for breast cancer prevention. The Study of Tamoxifen and Raloxifene (STAR) trial of nearly 20,000 postmenopausal women identified by the Gail model to be at high risk, demonstrated equivalence in incidence for invasive cancer. Patients taking raloxifene were noted to have a higher number of noninvasive cancers but fewer hysterectomies and endometrial cancer diagnoses.

There remain many questions about effective chemopreventive therapy particularly regarding the length of therapy. Emerging data support continued risk reduction with persistent therapy.

Primary care practices have new tools to identify and manage patients at increased risk for breast cancer. Incorporation of the Gail model into the preventive care of selected women could identify patients at high risk for invasive breast cancer who would benefit from chemoprevention and possible multidisciplinary follow-up.

Dr. Sibley is assistant professor of medicine at Dartmouth Medical School and is in the department of hematology and oncology at Dartmouth Hitchcock Medical Center in Lebanon, N.H. Dr. Golden is professor of medicine and public health at the University of Arkansas, Little Rock. Neither author reported having any conflicts of interest.

Breast cancer is the most common cancer in women the United States and affects nearly 200,000 individuals each year. More than half the cases occur in women aged over 65 years. On a positive note, 5-year survival now hovers around 90%.

While breast cancer is a heterogeneous disease, there are now more sophisticated risk models to identify patients with higher likelihood of developing the disease. Importantly, there are now reasonable interventions for high-risk women to reduce their incidence of breast cancer. Primary care offices should become familiar with risk assessment techniques and the potential value of chemopreventive strategies for high-risk women.

Many factors can increase the relative risk of development of breast cancer. Hormone replacement therapy, consumption of alcohol, menarche before age 12, late menopause, first childbirth after age 35, physical inactivity, and postmenopausal obesity modestly elevate the risk for the disease. Family history can have a substantial impact on risk. Having a first-degree relative with breast cancer increases one’s risk two- to fourfold. Personal histories of atypical hyperplasia or radiation therapy to the chest also elevate risk. Individuals with the BRCA mutation have up to an 80% increased risk of developing breast cancer over their lifetime.

Certain characteristics place patients at high risk for genetic predisposition for breast cancer. This can include a family history of cancer prior to 50 years of age; a family member with either breast cancer or breast and ovarian cancer; two close family members with breast, ovarian, or primary peritoneal cancers; or Ashkenazi Jewish ancestry.

Several mathematical models can calculate the risk for an individual patient and are available online. The Gail model is most widely used, especially for patients aged over 35 years. It can identify patients at high risk, which is defined as a 1.66% chance of developing breast cancer over the next 5 years.

Aside from greater surveillance and consideration of prophylactic mastectomy, chemoprevention is emerging as an important option for patients with higher likelihoods of developing breast cancer.

The National Surgical Adjuvant Breast and Bowel Project (NSABP) enrolled more than 13,000 women identified to be at high risk by the Gail model. Participants received tamoxifen or placebo and were followed for a median of 55 months. Overall, the risk reduction for invasive hormone receptor–positive cancer was 49% in the tamoxifen group. Certain subgroups, including women with atypical hyperplasia, had greater reductions in risk. There were other smaller studies that evaluated the same issue and showed variable (some nonstatistically significant) risk reduction in the tamoxifen groups. Study confounders include variations in use of hormone replacement therapy, in family history, and in prior hysterectomy status of study enrollees.

Overall, the benefit of tamoxifen between the four studies was a 38% reduction in the occurrence of hormone receptor–positive breast cancer (CI 8%-46%; P less than .001). Tamoxifen is used at 20 mg by mouth daily.

Of note, risk reduction was seen only in a hormone receptor–positive breast cancer, but not estrogen receptor–negative cancer. There are only limited data on the benefits of chemoprevention for women with BRCA mutations or a history of chest radiation.

Tamoxifen is a nonsteroidal mixed antagonist–agonist of the estrogen receptor. In breast tissue, tamoxifen blocks the binding of estrogen to tissue receptors. In other tissues such as bone and endometrium, however, tamoxifen is an estrogen agonist. While this is effective in reducing osteoclast activity and development of osteoporosis, it can lead to endometrial hyperplasia and subsequent adenocarcinoma. Other side effects include doubling the risk of deep venous thrombosis and an increased risk of cataract formation. In addition, tamoxifen interacts with SSRIs that can alter metabolism through the CYP2D6 pathway in the liver. This incomplete metabolism can promote increased rates of breast cancer recurrence in patients already receiving tamoxifen for established primary breast cancers. Paroxetine, fluoxetine, and sertraline are most prominently cited for this interaction.

Raloxifene is a selective reuptake estrogen modulator. Like tamoxifen, it can increase the risk for deep venous thrombosis but is associated with a lower risk for endometrial cancer.

Raloxifene trials for osteoporosis and cardiac disease were used to assess this agent for effectiveness in breast cancer chemoprevention. Raloxifene was used at 60 mg by mouth daily. Positive and encouraging findings have led to trials comparing raloxifene to tamoxifen for breast cancer prevention. The Study of Tamoxifen and Raloxifene (STAR) trial of nearly 20,000 postmenopausal women identified by the Gail model to be at high risk, demonstrated equivalence in incidence for invasive cancer. Patients taking raloxifene were noted to have a higher number of noninvasive cancers but fewer hysterectomies and endometrial cancer diagnoses.

There remain many questions about effective chemopreventive therapy particularly regarding the length of therapy. Emerging data support continued risk reduction with persistent therapy.

Primary care practices have new tools to identify and manage patients at increased risk for breast cancer. Incorporation of the Gail model into the preventive care of selected women could identify patients at high risk for invasive breast cancer who would benefit from chemoprevention and possible multidisciplinary follow-up.

Dr. Sibley is assistant professor of medicine at Dartmouth Medical School and is in the department of hematology and oncology at Dartmouth Hitchcock Medical Center in Lebanon, N.H. Dr. Golden is professor of medicine and public health at the University of Arkansas, Little Rock. Neither author reported having any conflicts of interest.

Breast cancer is the most common cancer in women the United States and affects nearly 200,000 individuals each year. More than half the cases occur in women aged over 65 years. On a positive note, 5-year survival now hovers around 90%.

While breast cancer is a heterogeneous disease, there are now more sophisticated risk models to identify patients with higher likelihood of developing the disease. Importantly, there are now reasonable interventions for high-risk women to reduce their incidence of breast cancer. Primary care offices should become familiar with risk assessment techniques and the potential value of chemopreventive strategies for high-risk women.

Many factors can increase the relative risk of development of breast cancer. Hormone replacement therapy, consumption of alcohol, menarche before age 12, late menopause, first childbirth after age 35, physical inactivity, and postmenopausal obesity modestly elevate the risk for the disease. Family history can have a substantial impact on risk. Having a first-degree relative with breast cancer increases one’s risk two- to fourfold. Personal histories of atypical hyperplasia or radiation therapy to the chest also elevate risk. Individuals with the BRCA mutation have up to an 80% increased risk of developing breast cancer over their lifetime.

Certain characteristics place patients at high risk for genetic predisposition for breast cancer. This can include a family history of cancer prior to 50 years of age; a family member with either breast cancer or breast and ovarian cancer; two close family members with breast, ovarian, or primary peritoneal cancers; or Ashkenazi Jewish ancestry.

Several mathematical models can calculate the risk for an individual patient and are available online. The Gail model is most widely used, especially for patients aged over 35 years. It can identify patients at high risk, which is defined as a 1.66% chance of developing breast cancer over the next 5 years.

Aside from greater surveillance and consideration of prophylactic mastectomy, chemoprevention is emerging as an important option for patients with higher likelihoods of developing breast cancer.

The National Surgical Adjuvant Breast and Bowel Project (NSABP) enrolled more than 13,000 women identified to be at high risk by the Gail model. Participants received tamoxifen or placebo and were followed for a median of 55 months. Overall, the risk reduction for invasive hormone receptor–positive cancer was 49% in the tamoxifen group. Certain subgroups, including women with atypical hyperplasia, had greater reductions in risk. There were other smaller studies that evaluated the same issue and showed variable (some nonstatistically significant) risk reduction in the tamoxifen groups. Study confounders include variations in use of hormone replacement therapy, in family history, and in prior hysterectomy status of study enrollees.

Overall, the benefit of tamoxifen between the four studies was a 38% reduction in the occurrence of hormone receptor–positive breast cancer (CI 8%-46%; P less than .001). Tamoxifen is used at 20 mg by mouth daily.

Of note, risk reduction was seen only in a hormone receptor–positive breast cancer, but not estrogen receptor–negative cancer. There are only limited data on the benefits of chemoprevention for women with BRCA mutations or a history of chest radiation.

Tamoxifen is a nonsteroidal mixed antagonist–agonist of the estrogen receptor. In breast tissue, tamoxifen blocks the binding of estrogen to tissue receptors. In other tissues such as bone and endometrium, however, tamoxifen is an estrogen agonist. While this is effective in reducing osteoclast activity and development of osteoporosis, it can lead to endometrial hyperplasia and subsequent adenocarcinoma. Other side effects include doubling the risk of deep venous thrombosis and an increased risk of cataract formation. In addition, tamoxifen interacts with SSRIs that can alter metabolism through the CYP2D6 pathway in the liver. This incomplete metabolism can promote increased rates of breast cancer recurrence in patients already receiving tamoxifen for established primary breast cancers. Paroxetine, fluoxetine, and sertraline are most prominently cited for this interaction.

Raloxifene is a selective reuptake estrogen modulator. Like tamoxifen, it can increase the risk for deep venous thrombosis but is associated with a lower risk for endometrial cancer.

Raloxifene trials for osteoporosis and cardiac disease were used to assess this agent for effectiveness in breast cancer chemoprevention. Raloxifene was used at 60 mg by mouth daily. Positive and encouraging findings have led to trials comparing raloxifene to tamoxifen for breast cancer prevention. The Study of Tamoxifen and Raloxifene (STAR) trial of nearly 20,000 postmenopausal women identified by the Gail model to be at high risk, demonstrated equivalence in incidence for invasive cancer. Patients taking raloxifene were noted to have a higher number of noninvasive cancers but fewer hysterectomies and endometrial cancer diagnoses.

There remain many questions about effective chemopreventive therapy particularly regarding the length of therapy. Emerging data support continued risk reduction with persistent therapy.

Primary care practices have new tools to identify and manage patients at increased risk for breast cancer. Incorporation of the Gail model into the preventive care of selected women could identify patients at high risk for invasive breast cancer who would benefit from chemoprevention and possible multidisciplinary follow-up.

Dr. Sibley is assistant professor of medicine at Dartmouth Medical School and is in the department of hematology and oncology at Dartmouth Hitchcock Medical Center in Lebanon, N.H. Dr. Golden is professor of medicine and public health at the University of Arkansas, Little Rock. Neither author reported having any conflicts of interest.

Breast cancer is the most common cancer in women the United States and affects nearly 200,000 individuals each year. More than half the cases occur in women aged over 65 years. On a positive note, 5-year survival now hovers around 90%.

While breast cancer is a heterogeneous disease, there are now more sophisticated risk models to identify patients with higher likelihood of developing the disease. Importantly, there are now reasonable interventions for high-risk women to reduce their incidence of breast cancer. Primary care offices should become familiar with risk assessment techniques and the potential value of chemopreventive strategies for high-risk women.

Many factors can increase the relative risk of development of breast cancer. Hormone replacement therapy, consumption of alcohol, menarche before age 12, late menopause, first childbirth after age 35, physical inactivity, and postmenopausal obesity modestly elevate the risk for the disease. Family history can have a substantial impact on risk. Having a first-degree relative with breast cancer increases one’s risk two- to fourfold. Personal histories of atypical hyperplasia or radiation therapy to the chest also elevate risk. Individuals with the BRCA mutation have up to an 80% increased risk of developing breast cancer over their lifetime.

Certain characteristics place patients at high risk for genetic predisposition for breast cancer. This can include a family history of cancer prior to 50 years of age; a family member with either breast cancer or breast and ovarian cancer; two close family members with breast, ovarian, or primary peritoneal cancers; or Ashkenazi Jewish ancestry.

Several mathematical models can calculate the risk for an individual patient and are available online. The Gail model is most widely used, especially for patients aged over 35 years. It can identify patients at high risk, which is defined as a 1.66% chance of developing breast cancer over the next 5 years.

Aside from greater surveillance and consideration of prophylactic mastectomy, chemoprevention is emerging as an important option for patients with higher likelihoods of developing breast cancer.

The National Surgical Adjuvant Breast and Bowel Project (NSABP) enrolled more than 13,000 women identified to be at high risk by the Gail model. Participants received tamoxifen or placebo and were followed for a median of 55 months. Overall, the risk reduction for invasive hormone receptor–positive cancer was 49% in the tamoxifen group. Certain subgroups, including women with atypical hyperplasia, had greater reductions in risk. There were other smaller studies that evaluated the same issue and showed variable (some nonstatistically significant) risk reduction in the tamoxifen groups. Study confounders include variations in use of hormone replacement therapy, in family history, and in prior hysterectomy status of study enrollees.

Overall, the benefit of tamoxifen between the four studies was a 38% reduction in the occurrence of hormone receptor–positive breast cancer (CI 8%-46%; P less than .001). Tamoxifen is used at 20 mg by mouth daily.

Of note, risk reduction was seen only in a hormone receptor–positive breast cancer, but not estrogen receptor–negative cancer. There are only limited data on the benefits of chemoprevention for women with BRCA mutations or a history of chest radiation.

Tamoxifen is a nonsteroidal mixed antagonist–agonist of the estrogen receptor. In breast tissue, tamoxifen blocks the binding of estrogen to tissue receptors. In other tissues such as bone and endometrium, however, tamoxifen is an estrogen agonist. While this is effective in reducing osteoclast activity and development of osteoporosis, it can lead to endometrial hyperplasia and subsequent adenocarcinoma. Other side effects include doubling the risk of deep venous thrombosis and an increased risk of cataract formation. In addition, tamoxifen interacts with SSRIs that can alter metabolism through the CYP2D6 pathway in the liver. This incomplete metabolism can promote increased rates of breast cancer recurrence in patients already receiving tamoxifen for established primary breast cancers. Paroxetine, fluoxetine, and sertraline are most prominently cited for this interaction.

Raloxifene is a selective reuptake estrogen modulator. Like tamoxifen, it can increase the risk for deep venous thrombosis but is associated with a lower risk for endometrial cancer.

Raloxifene trials for osteoporosis and cardiac disease were used to assess this agent for effectiveness in breast cancer chemoprevention. Raloxifene was used at 60 mg by mouth daily. Positive and encouraging findings have led to trials comparing raloxifene to tamoxifen for breast cancer prevention. The Study of Tamoxifen and Raloxifene (STAR) trial of nearly 20,000 postmenopausal women identified by the Gail model to be at high risk, demonstrated equivalence in incidence for invasive cancer. Patients taking raloxifene were noted to have a higher number of noninvasive cancers but fewer hysterectomies and endometrial cancer diagnoses.

There remain many questions about effective chemopreventive therapy particularly regarding the length of therapy. Emerging data support continued risk reduction with persistent therapy.

Primary care practices have new tools to identify and manage patients at increased risk for breast cancer. Incorporation of the Gail model into the preventive care of selected women could identify patients at high risk for invasive breast cancer who would benefit from chemoprevention and possible multidisciplinary follow-up.

Dr. Anjali Sibley is assistant professor of medicine at Dartmouth Medical School and is in the department of hematology and oncology at Dartmouth Hitchcock Medical Center in Lebanon, N.H. Dr. William E. Golden is professor of medicine and public health at the University of Arkansas, Little Rock. Neither author reported having any conflicts of interest.

Breast cancer is the most common cancer in women the United States and affects nearly 200,000 individuals each year. More than half the cases occur in women aged over 65 years. On a positive note, 5-year survival now hovers around 90%.

While breast cancer is a heterogeneous disease, there are now more sophisticated risk models to identify patients with higher likelihood of developing the disease. Importantly, there are now reasonable interventions for high-risk women to reduce their incidence of breast cancer. Primary care offices should become familiar with risk assessment techniques and the potential value of chemopreventive strategies for high-risk women.

Many factors can increase the relative risk of development of breast cancer. Hormone replacement therapy, consumption of alcohol, menarche before age 12, late menopause, first childbirth after age 35, physical inactivity, and postmenopausal obesity modestly elevate the risk for the disease. Family history can have a substantial impact on risk. Having a first-degree relative with breast cancer increases one’s risk two- to fourfold. Personal histories of atypical hyperplasia or radiation therapy to the chest also elevate risk. Individuals with the BRCA mutation have up to an 80% increased risk of developing breast cancer over their lifetime.

Certain characteristics place patients at high risk for genetic predisposition for breast cancer. This can include a family history of cancer prior to 50 years of age; a family member with either breast cancer or breast and ovarian cancer; two close family members with breast, ovarian, or primary peritoneal cancers; or Ashkenazi Jewish ancestry.

Several mathematical models can calculate the risk for an individual patient and are available online. The Gail model is most widely used, especially for patients aged over 35 years. It can identify patients at high risk, which is defined as a 1.66% chance of developing breast cancer over the next 5 years.

Aside from greater surveillance and consideration of prophylactic mastectomy, chemoprevention is emerging as an important option for patients with higher likelihoods of developing breast cancer.

The National Surgical Adjuvant Breast and Bowel Project (NSABP) enrolled more than 13,000 women identified to be at high risk by the Gail model. Participants received tamoxifen or placebo and were followed for a median of 55 months. Overall, the risk reduction for invasive hormone receptor–positive cancer was 49% in the tamoxifen group. Certain subgroups, including women with atypical hyperplasia, had greater reductions in risk. There were other smaller studies that evaluated the same issue and showed variable (some nonstatistically significant) risk reduction in the tamoxifen groups. Study confounders include variations in use of hormone replacement therapy, in family history, and in prior hysterectomy status of study enrollees.

Overall, the benefit of tamoxifen between the four studies was a 38% reduction in the occurrence of hormone receptor–positive breast cancer (CI 8%-46%; P less than .001). Tamoxifen is used at 20 mg by mouth daily.

Of note, risk reduction was seen only in a hormone receptor–positive breast cancer, but not estrogen receptor–negative cancer. There are only limited data on the benefits of chemoprevention for women with BRCA mutations or a history of chest radiation.

Tamoxifen is a nonsteroidal mixed antagonist–agonist of the estrogen receptor. In breast tissue, tamoxifen blocks the binding of estrogen to tissue receptors. In other tissues such as bone and endometrium, however, tamoxifen is an estrogen agonist. While this is effective in reducing osteoclast activity and development of osteoporosis, it can lead to endometrial hyperplasia and subsequent adenocarcinoma. Other side effects include doubling the risk of deep venous thrombosis and an increased risk of cataract formation. In addition, tamoxifen interacts with SSRIs that can alter metabolism through the CYP2D6 pathway in the liver. This incomplete metabolism can promote increased rates of breast cancer recurrence in patients already receiving tamoxifen for established primary breast cancers. Paroxetine, fluoxetine, and sertraline are most prominently cited for this interaction.

Raloxifene is a selective reuptake estrogen modulator. Like tamoxifen, it can increase the risk for deep venous thrombosis but is associated with a lower risk for endometrial cancer.

Raloxifene trials for osteoporosis and cardiac disease were used to assess this agent for effectiveness in breast cancer chemoprevention. Raloxifene was used at 60 mg by mouth daily. Positive and encouraging findings have led to trials comparing raloxifene to tamoxifen for breast cancer prevention. The Study of Tamoxifen and Raloxifene (STAR) trial of nearly 20,000 postmenopausal women identified by the Gail model to be at high risk, demonstrated equivalence in incidence for invasive cancer. Patients taking raloxifene were noted to have a higher number of noninvasive cancers but fewer hysterectomies and endometrial cancer diagnoses.

There remain many questions about effective chemopreventive therapy particularly regarding the length of therapy. Emerging data support continued risk reduction with persistent therapy.

Primary care practices have new tools to identify and manage patients at increased risk for breast cancer. Incorporation of the Gail model into the preventive care of selected women could identify patients at high risk for invasive breast cancer who would benefit from chemoprevention and possible multidisciplinary follow-up.

Dr. Anjali Sibley is assistant professor of medicine at Dartmouth Medical School and is in the department of hematology and oncology at Dartmouth Hitchcock Medical Center in Lebanon, N.H. Dr. William E. Golden is professor of medicine and public health at the University of Arkansas, Little Rock. Neither author reported having any conflicts of interest.

Breast cancer is the most common cancer in women the United States and affects nearly 200,000 individuals each year. More than half the cases occur in women aged over 65 years. On a positive note, 5-year survival now hovers around 90%.

While breast cancer is a heterogeneous disease, there are now more sophisticated risk models to identify patients with higher likelihood of developing the disease. Importantly, there are now reasonable interventions for high-risk women to reduce their incidence of breast cancer. Primary care offices should become familiar with risk assessment techniques and the potential value of chemopreventive strategies for high-risk women.

Many factors can increase the relative risk of development of breast cancer. Hormone replacement therapy, consumption of alcohol, menarche before age 12, late menopause, first childbirth after age 35, physical inactivity, and postmenopausal obesity modestly elevate the risk for the disease. Family history can have a substantial impact on risk. Having a first-degree relative with breast cancer increases one’s risk two- to fourfold. Personal histories of atypical hyperplasia or radiation therapy to the chest also elevate risk. Individuals with the BRCA mutation have up to an 80% increased risk of developing breast cancer over their lifetime.

Certain characteristics place patients at high risk for genetic predisposition for breast cancer. This can include a family history of cancer prior to 50 years of age; a family member with either breast cancer or breast and ovarian cancer; two close family members with breast, ovarian, or primary peritoneal cancers; or Ashkenazi Jewish ancestry.

Several mathematical models can calculate the risk for an individual patient and are available online. The Gail model is most widely used, especially for patients aged over 35 years. It can identify patients at high risk, which is defined as a 1.66% chance of developing breast cancer over the next 5 years.

Aside from greater surveillance and consideration of prophylactic mastectomy, chemoprevention is emerging as an important option for patients with higher likelihoods of developing breast cancer.

The National Surgical Adjuvant Breast and Bowel Project (NSABP) enrolled more than 13,000 women identified to be at high risk by the Gail model. Participants received tamoxifen or placebo and were followed for a median of 55 months. Overall, the risk reduction for invasive hormone receptor–positive cancer was 49% in the tamoxifen group. Certain subgroups, including women with atypical hyperplasia, had greater reductions in risk. There were other smaller studies that evaluated the same issue and showed variable (some nonstatistically significant) risk reduction in the tamoxifen groups. Study confounders include variations in use of hormone replacement therapy, in family history, and in prior hysterectomy status of study enrollees.

Overall, the benefit of tamoxifen between the four studies was a 38% reduction in the occurrence of hormone receptor–positive breast cancer (CI 8%-46%; P less than .001). Tamoxifen is used at 20 mg by mouth daily.

Of note, risk reduction was seen only in a hormone receptor–positive breast cancer, but not estrogen receptor–negative cancer. There are only limited data on the benefits of chemoprevention for women with BRCA mutations or a history of chest radiation.

Tamoxifen is a nonsteroidal mixed antagonist–agonist of the estrogen receptor. In breast tissue, tamoxifen blocks the binding of estrogen to tissue receptors. In other tissues such as bone and endometrium, however, tamoxifen is an estrogen agonist. While this is effective in reducing osteoclast activity and development of osteoporosis, it can lead to endometrial hyperplasia and subsequent adenocarcinoma. Other side effects include doubling the risk of deep venous thrombosis and an increased risk of cataract formation. In addition, tamoxifen interacts with SSRIs that can alter metabolism through the CYP2D6 pathway in the liver. This incomplete metabolism can promote increased rates of breast cancer recurrence in patients already receiving tamoxifen for established primary breast cancers. Paroxetine, fluoxetine, and sertraline are most prominently cited for this interaction.

Raloxifene is a selective reuptake estrogen modulator. Like tamoxifen, it can increase the risk for deep venous thrombosis but is associated with a lower risk for endometrial cancer.

Raloxifene trials for osteoporosis and cardiac disease were used to assess this agent for effectiveness in breast cancer chemoprevention. Raloxifene was used at 60 mg by mouth daily. Positive and encouraging findings have led to trials comparing raloxifene to tamoxifen for breast cancer prevention. The Study of Tamoxifen and Raloxifene (STAR) trial of nearly 20,000 postmenopausal women identified by the Gail model to be at high risk, demonstrated equivalence in incidence for invasive cancer. Patients taking raloxifene were noted to have a higher number of noninvasive cancers but fewer hysterectomies and endometrial cancer diagnoses.

There remain many questions about effective chemopreventive therapy particularly regarding the length of therapy. Emerging data support continued risk reduction with persistent therapy.

Primary care practices have new tools to identify and manage patients at increased risk for breast cancer. Incorporation of the Gail model into the preventive care of selected women could identify patients at high risk for invasive breast cancer who would benefit from chemoprevention and possible multidisciplinary follow-up.

Dr. Anjali Sibley is assistant professor of medicine at Dartmouth Medical School and is in the department of hematology and oncology at Dartmouth Hitchcock Medical Center in Lebanon, N.H. Dr. William E. Golden is professor of medicine and public health at the University of Arkansas, Little Rock. Neither author reported having any conflicts of interest.

It would be hard to imagine a more interesting year for health care than 2010. On the other hand, implementation or "refudiation" of health reform could be déjà vu all over again. As we start the 14th year of the Effective Physician, we offer our thoughts on seven hot topics for the coming 12 months.

State Legislation

Frustrated at the federal level, opponents of health care reform are blanketing state legislatures with bills to exclude physicians and patients from mandatory participation in specific health systems. Perhaps the only thing odder than congressional debate about health care will be health care debates at the state level among local politicians. There may not be a consistent plan for many years to come.

Medicaid on the Ropes

Medicaid in many states cannot pay for current obligations, let alone a 20% increase in enrollment in 2014. Many states have reduced their Medicaid staffing by 20%, despite increases in enrollment. It will be hard to maintain reimbursement, sustain physician participation, and protect benefits to the disabled and mentally ill.

Tough Choices

The elimination of coverage for some transplantation procedures in Arizona is just the beginning of the adult conversation needed regarding health technology, public dollars, and effectiveness of care. Case-by-case denials of services make headlines, but the context of increasing taxes to pay for ineffective health services could result in new policy. The health professional community will have to start reviewing care across specialties to ensure that resources are available for effective services for those patients who will benefit. New priorities and mechanisms of identifying those priorities will be inevitable.

Exciting New Drugs

Internal medicine has not really seen new blockbuster medications for many years. The imminent release of thrombin and factor Xa inhibitors to reduce thromboembolism in atrial fibrillation is a long-awaited event. Similarly, the summer of 2011 may see the release of new antiviral agents that could double the cure rate in patients with the most common genotype of hepatitis C and reduce the total number of weeks of interferon therapy needed to achieve this improved outcome. Successful release of these agents could have a huge impact in internal medicine offices next year.

Licensure Heats Up

A dull topic for decades, renewal of licensure may soon require demonstration of continued competency through board recertification or other standardized processes. Meanwhile, the expansion of privileges for nurse practitioners and physician assistants to improve access to primary care will challenge licensure authorities. It seems odd that while everyone advocates greater use of team-based care, we are marching toward siloed licensure authorities for nurses and physicians, which only aggravates fragmentation of care. As clinical care grows more complex and patients’ needs expand, perhaps the best option is to unify nursing, medical, and pharmacy licensure boards into one entity that would credential professionals in accordance with capabilities and the functioning of team-based care. Having separate standard-setting agencies for nurse practitioners and physicians no longer make sense.

Rebooting HIT

The federal government’s stimulus program to support adoption of health information technology in clinical settings will probably hit more than a few potholes as clinical sites struggle to implement meaningful use, software vendors strive to meet uncertain government requirements, and government agencies miss important deadlines. The attempt to integrate software programs with clinical routine to create networks of clinical enterprises will temper the optimism of policy designers and health reformers. There is still a long road ahead.

Uncertainty for U.S. Medical School Grads

The growth of U.S. medical school enrollment, coupled with more competitive international and U.S. offshore medical school graduates, has created a relative shortage of first-year residency positions. Last year – for the first time – unassigned American medical school graduates had difficulty obtaining any residency position in the scramble after Match Day. This trend is projected to worsen in 2011. Moreover, good international and offshore American medical school grads have outperformed weaker U.S. medical grads in residency programs for the past several years. Graduating from an American medical school is no longer a guarantee of postgraduate training for those who struggle to graduate. Finally, the federal budget cutters once again are taking aim at graduate medical education subsidies. Financial support for those who get training positions may be at substantial risk.

In the meantime, we hope that the Effective Physician can continue to offer guidance on evidence-based care for your patients. Clinicians remain on solid ground in applying good clinical science: It is the pathway to professional satisfaction and community support of our daily efforts.

This column, "The Effective Physician," regularly appears in Internal Medicine News, an Elsevier publication. Dr. Golden is professor of medicine and public health and Dr. Hopkins is program director for the internal medicine/pediatrics combined residency program at the University of Arkansas, Little Rock.

It would be hard to imagine a more interesting year for health care than 2010. On the other hand, implementation or "refudiation" of health reform could be déjà vu all over again. As we start the 14th year of the Effective Physician, we offer our thoughts on seven hot topics for the coming 12 months.

State Legislation

Frustrated at the federal level, opponents of health care reform are blanketing state legislatures with bills to exclude physicians and patients from mandatory participation in specific health systems. Perhaps the only thing odder than congressional debate about health care will be health care debates at the state level among local politicians. There may not be a consistent plan for many years to come.

Medicaid on the Ropes

Medicaid in many states cannot pay for current obligations, let alone a 20% increase in enrollment in 2014. Many states have reduced their Medicaid staffing by 20%, despite increases in enrollment. It will be hard to maintain reimbursement, sustain physician participation, and protect benefits to the disabled and mentally ill.

Tough Choices

The elimination of coverage for some transplantation procedures in Arizona is just the beginning of the adult conversation needed regarding health technology, public dollars, and effectiveness of care. Case-by-case denials of services make headlines, but the context of increasing taxes to pay for ineffective health services could result in new policy. The health professional community will have to start reviewing care across specialties to ensure that resources are available for effective services for those patients who will benefit. New priorities and mechanisms of identifying those priorities will be inevitable.

Exciting New Drugs

Internal medicine has not really seen new blockbuster medications for many years. The imminent release of thrombin and factor Xa inhibitors to reduce thromboembolism in atrial fibrillation is a long-awaited event. Similarly, the summer of 2011 may see the release of new antiviral agents that could double the cure rate in patients with the most common genotype of hepatitis C and reduce the total number of weeks of interferon therapy needed to achieve this improved outcome. Successful release of these agents could have a huge impact in internal medicine offices next year.

Licensure Heats Up

A dull topic for decades, renewal of licensure may soon require demonstration of continued competency through board recertification or other standardized processes. Meanwhile, the expansion of privileges for nurse practitioners and physician assistants to improve access to primary care will challenge licensure authorities. It seems odd that while everyone advocates greater use of team-based care, we are marching toward siloed licensure authorities for nurses and physicians, which only aggravates fragmentation of care. As clinical care grows more complex and patients’ needs expand, perhaps the best option is to unify nursing, medical, and pharmacy licensure boards into one entity that would credential professionals in accordance with capabilities and the functioning of team-based care. Having separate standard-setting agencies for nurse practitioners and physicians no longer make sense.

Rebooting HIT

The federal government’s stimulus program to support adoption of health information technology in clinical settings will probably hit more than a few potholes as clinical sites struggle to implement meaningful use, software vendors strive to meet uncertain government requirements, and government agencies miss important deadlines. The attempt to integrate software programs with clinical routine to create networks of clinical enterprises will temper the optimism of policy designers and health reformers. There is still a long road ahead.

Uncertainty for U.S. Medical School Grads

The growth of U.S. medical school enrollment, coupled with more competitive international and U.S. offshore medical school graduates, has created a relative shortage of first-year residency positions. Last year – for the first time – unassigned American medical school graduates had difficulty obtaining any residency position in the scramble after Match Day. This trend is projected to worsen in 2011. Moreover, good international and offshore American medical school grads have outperformed weaker U.S. medical grads in residency programs for the past several years. Graduating from an American medical school is no longer a guarantee of postgraduate training for those who struggle to graduate. Finally, the federal budget cutters once again are taking aim at graduate medical education subsidies. Financial support for those who get training positions may be at substantial risk.

In the meantime, we hope that the Effective Physician can continue to offer guidance on evidence-based care for your patients. Clinicians remain on solid ground in applying good clinical science: It is the pathway to professional satisfaction and community support of our daily efforts.

This column, "The Effective Physician," regularly appears in Internal Medicine News, an Elsevier publication. Dr. Golden is professor of medicine and public health and Dr. Hopkins is program director for the internal medicine/pediatrics combined residency program at the University of Arkansas, Little Rock.

It would be hard to imagine a more interesting year for health care than 2010. On the other hand, implementation or "refudiation" of health reform could be déjà vu all over again. As we start the 14th year of the Effective Physician, we offer our thoughts on seven hot topics for the coming 12 months.

State Legislation

Frustrated at the federal level, opponents of health care reform are blanketing state legislatures with bills to exclude physicians and patients from mandatory participation in specific health systems. Perhaps the only thing odder than congressional debate about health care will be health care debates at the state level among local politicians. There may not be a consistent plan for many years to come.

Medicaid on the Ropes

Medicaid in many states cannot pay for current obligations, let alone a 20% increase in enrollment in 2014. Many states have reduced their Medicaid staffing by 20%, despite increases in enrollment. It will be hard to maintain reimbursement, sustain physician participation, and protect benefits to the disabled and mentally ill.

Tough Choices

The elimination of coverage for some transplantation procedures in Arizona is just the beginning of the adult conversation needed regarding health technology, public dollars, and effectiveness of care. Case-by-case denials of services make headlines, but the context of increasing taxes to pay for ineffective health services could result in new policy. The health professional community will have to start reviewing care across specialties to ensure that resources are available for effective services for those patients who will benefit. New priorities and mechanisms of identifying those priorities will be inevitable.

Exciting New Drugs

Internal medicine has not really seen new blockbuster medications for many years. The imminent release of thrombin and factor Xa inhibitors to reduce thromboembolism in atrial fibrillation is a long-awaited event. Similarly, the summer of 2011 may see the release of new antiviral agents that could double the cure rate in patients with the most common genotype of hepatitis C and reduce the total number of weeks of interferon therapy needed to achieve this improved outcome. Successful release of these agents could have a huge impact in internal medicine offices next year.

Licensure Heats Up

A dull topic for decades, renewal of licensure may soon require demonstration of continued competency through board recertification or other standardized processes. Meanwhile, the expansion of privileges for nurse practitioners and physician assistants to improve access to primary care will challenge licensure authorities. It seems odd that while everyone advocates greater use of team-based care, we are marching toward siloed licensure authorities for nurses and physicians, which only aggravates fragmentation of care. As clinical care grows more complex and patients’ needs expand, perhaps the best option is to unify nursing, medical, and pharmacy licensure boards into one entity that would credential professionals in accordance with capabilities and the functioning of team-based care. Having separate standard-setting agencies for nurse practitioners and physicians no longer make sense.

Rebooting HIT

The federal government’s stimulus program to support adoption of health information technology in clinical settings will probably hit more than a few potholes as clinical sites struggle to implement meaningful use, software vendors strive to meet uncertain government requirements, and government agencies miss important deadlines. The attempt to integrate software programs with clinical routine to create networks of clinical enterprises will temper the optimism of policy designers and health reformers. There is still a long road ahead.

Uncertainty for U.S. Medical School Grads

The growth of U.S. medical school enrollment, coupled with more competitive international and U.S. offshore medical school graduates, has created a relative shortage of first-year residency positions. Last year – for the first time – unassigned American medical school graduates had difficulty obtaining any residency position in the scramble after Match Day. This trend is projected to worsen in 2011. Moreover, good international and offshore American medical school grads have outperformed weaker U.S. medical grads in residency programs for the past several years. Graduating from an American medical school is no longer a guarantee of postgraduate training for those who struggle to graduate. Finally, the federal budget cutters once again are taking aim at graduate medical education subsidies. Financial support for those who get training positions may be at substantial risk.

In the meantime, we hope that the Effective Physician can continue to offer guidance on evidence-based care for your patients. Clinicians remain on solid ground in applying good clinical science: It is the pathway to professional satisfaction and community support of our daily efforts.

This column, "The Effective Physician," regularly appears in Internal Medicine News, an Elsevier publication. Dr. Golden is professor of medicine and public health and Dr. Hopkins is program director for the internal medicine/pediatrics combined residency program at the University of Arkansas, Little Rock.

Over 8 million people seek emergency department (ED) attention every year for assessment of chest pain. The American Heart Association recently issued a scientific statement to give guidance on rapid, effective approaches to the assessment of such patients.

Conclusions

Most patients who present with chest pain to ED settings do not have acute ischemia: Less than 5% have an ST segment elevation myocardial infarction, and up to 25% can have a non–ST segment elevation event. Up to 7% of patients with chest pain after cocaine exposure have infarctions.

At the same time, up to 2% of patients with acute coronary syndromes (ACS) are inadvertently discharged from EDs with potentially twice the risk-adjusted mortality of patients admitted for management of acute ischemia.

Symptom-limited treadmill stress testing is felt to be safe at 8-12 hours for low- and intermediate-risk chest pain patients who have normal baseline EKGs and capacity to exercise, and are not taking digoxin.

Ischemia induced during stress protocols for echocardiography or myocardial perfusion imaging (MPI) indicates impaired coronary perfusion in the face of increased oxygen demand. MPI also can be used to detect rest ischemia indicating impaired regional myocardial perfusion, a hallmark of the ACS.

Both stress echocardiography (sensitivity: 86%; specificity: 81%) and MPI (87%; 73%) are more effective in detecting coronary artery disease than exercise treadmill testing (70%; 75%). However, while MPI is an effective test, it is associated with considerable radiation exposure.

Use of pharmacologic agents can be substituted for exercise in patients unable to exercise according to modified Bruce protocols. Dobutamine increases myocardial demand. Vasodilators such as adenosine, dipyridamole, and regadenoson simulate exercise stress conditions by dilating coronary arteries and creating maldistribution of myocardial perfusion.

A major clinical trial is ongoing to assess the value of CT coronary arteriography, which has a very high negative predictive value, in assessing chest pain syndrome patients in the ED.

As many as 20%-25% of patients with negative chest pain unit evaluations present again for similar evaluations.

Implementation

The goal of ED evaluation of chest pain is the exclusion of ACS and other urgent conditions as appropriate diagnoses. Assessment of the presence of coronary artery disease is best handled in other settings. Experience with chest pain units and accelerated diagnostic protocols have provided effective evidence-based strategies for triaging these patients.

While classic anginal symptoms can aid in the evaluation of acute chest pain, ACS patients can present with atypical or confusing complaints and require care assessment by evaluating health professionals. Nausea and diaphoresis associated with severe chest pain are highly associated with acute ischemia, but elderly patients may have predominantly respiratory complaints.

Patients with sudden-onset, severe chest pain should be considered for pneumothorax, pulmonary embolus, or aortic dissection.

Patients at low risk for myocardial infarction (less than 5%) should be identified by current symptoms, past history, and a new electrocardiogram. These patients have normal EKGs, normal initial cardiac injury lab findings, and stable hemodynamics and cardiac rhythm. The Thrombolysis in Myocardial Infarction (TIMI) risk score is widely used, but has not performed consistently for low-risk populations.

Patients with acute ST segment elevation frequently have near-total or total coronary occlusion and are candidates for reperfusion interventions.

Patients who present during the first 6 hours of chest pain onset and who have negative cardiac markers should be retested after 8 hours to validate the negative results. Newer assays of troponin have good sensitivity and specificity, and are preferred over creatine kinase MB and myoglobin measurement. Laboratories should return results within an hour of specimen sampling or else point-of-service assessment should be considered. B-type natriuretic peptide, while useful for congestive heart failure evaluation, does not offer value in the assessment of acute ischemia.

For patients with indeterminant initial presentations, chest pain protocols can help structure observation. Exercise stress testing is optional in patients with cocaine-related chest pain after a negative period of observation and testing.

Patients who have no additional chest discomfort, undiagnostic initial and follow-up EKGs, and negative injury lab values can be discharged without stress testing for outpatient follow-up investigations.

Repeat treadmill stress testing has limited value in patients with a previous negative evaluation for chest pain in an emergency setting. These patients may eventually require coronary arteriography as negative cardiac caths, in comparison to noninvasive evaluation, reduce repeat ED chest pain evaluations by more than 50%.

Reference

Amsterdam EA et al. Testing of Low-Risk Patients Presenting to the Emergency Department with Chest Pain (Circulation 2010;122:756-76).

This column, "The Effective Physician," appears regularly in Internal Medicine News, an Elsevier publication. Dr. Golden is professor of medicine and public health and Dr. Hopkins is program director for the internal medicine/pediatrics combined residency program at the University of Arkansas, Little Rock.

Over 8 million people seek emergency department (ED) attention every year for assessment of chest pain. The American Heart Association recently issued a scientific statement to give guidance on rapid, effective approaches to the assessment of such patients.

Conclusions

Most patients who present with chest pain to ED settings do not have acute ischemia: Less than 5% have an ST segment elevation myocardial infarction, and up to 25% can have a non–ST segment elevation event. Up to 7% of patients with chest pain after cocaine exposure have infarctions.

At the same time, up to 2% of patients with acute coronary syndromes (ACS) are inadvertently discharged from EDs with potentially twice the risk-adjusted mortality of patients admitted for management of acute ischemia.

Symptom-limited treadmill stress testing is felt to be safe at 8-12 hours for low- and intermediate-risk chest pain patients who have normal baseline EKGs and capacity to exercise, and are not taking digoxin.

Ischemia induced during stress protocols for echocardiography or myocardial perfusion imaging (MPI) indicates impaired coronary perfusion in the face of increased oxygen demand. MPI also can be used to detect rest ischemia indicating impaired regional myocardial perfusion, a hallmark of the ACS.

Both stress echocardiography (sensitivity: 86%; specificity: 81%) and MPI (87%; 73%) are more effective in detecting coronary artery disease than exercise treadmill testing (70%; 75%). However, while MPI is an effective test, it is associated with considerable radiation exposure.

Use of pharmacologic agents can be substituted for exercise in patients unable to exercise according to modified Bruce protocols. Dobutamine increases myocardial demand. Vasodilators such as adenosine, dipyridamole, and regadenoson simulate exercise stress conditions by dilating coronary arteries and creating maldistribution of myocardial perfusion.

A major clinical trial is ongoing to assess the value of CT coronary arteriography, which has a very high negative predictive value, in assessing chest pain syndrome patients in the ED.

As many as 20%-25% of patients with negative chest pain unit evaluations present again for similar evaluations.

Implementation

The goal of ED evaluation of chest pain is the exclusion of ACS and other urgent conditions as appropriate diagnoses. Assessment of the presence of coronary artery disease is best handled in other settings. Experience with chest pain units and accelerated diagnostic protocols have provided effective evidence-based strategies for triaging these patients.

While classic anginal symptoms can aid in the evaluation of acute chest pain, ACS patients can present with atypical or confusing complaints and require care assessment by evaluating health professionals. Nausea and diaphoresis associated with severe chest pain are highly associated with acute ischemia, but elderly patients may have predominantly respiratory complaints.

Patients with sudden-onset, severe chest pain should be considered for pneumothorax, pulmonary embolus, or aortic dissection.

Patients at low risk for myocardial infarction (less than 5%) should be identified by current symptoms, past history, and a new electrocardiogram. These patients have normal EKGs, normal initial cardiac injury lab findings, and stable hemodynamics and cardiac rhythm. The Thrombolysis in Myocardial Infarction (TIMI) risk score is widely used, but has not performed consistently for low-risk populations.

Patients with acute ST segment elevation frequently have near-total or total coronary occlusion and are candidates for reperfusion interventions.

Patients who present during the first 6 hours of chest pain onset and who have negative cardiac markers should be retested after 8 hours to validate the negative results. Newer assays of troponin have good sensitivity and specificity, and are preferred over creatine kinase MB and myoglobin measurement. Laboratories should return results within an hour of specimen sampling or else point-of-service assessment should be considered. B-type natriuretic peptide, while useful for congestive heart failure evaluation, does not offer value in the assessment of acute ischemia.

For patients with indeterminant initial presentations, chest pain protocols can help structure observation. Exercise stress testing is optional in patients with cocaine-related chest pain after a negative period of observation and testing.

Patients who have no additional chest discomfort, undiagnostic initial and follow-up EKGs, and negative injury lab values can be discharged without stress testing for outpatient follow-up investigations.

Repeat treadmill stress testing has limited value in patients with a previous negative evaluation for chest pain in an emergency setting. These patients may eventually require coronary arteriography as negative cardiac caths, in comparison to noninvasive evaluation, reduce repeat ED chest pain evaluations by more than 50%.

Reference

Amsterdam EA et al. Testing of Low-Risk Patients Presenting to the Emergency Department with Chest Pain (Circulation 2010;122:756-76).

This column, "The Effective Physician," appears regularly in Internal Medicine News, an Elsevier publication. Dr. Golden is professor of medicine and public health and Dr. Hopkins is program director for the internal medicine/pediatrics combined residency program at the University of Arkansas, Little Rock.

Over 8 million people seek emergency department (ED) attention every year for assessment of chest pain. The American Heart Association recently issued a scientific statement to give guidance on rapid, effective approaches to the assessment of such patients.

Conclusions

Most patients who present with chest pain to ED settings do not have acute ischemia: Less than 5% have an ST segment elevation myocardial infarction, and up to 25% can have a non–ST segment elevation event. Up to 7% of patients with chest pain after cocaine exposure have infarctions.

At the same time, up to 2% of patients with acute coronary syndromes (ACS) are inadvertently discharged from EDs with potentially twice the risk-adjusted mortality of patients admitted for management of acute ischemia.

Symptom-limited treadmill stress testing is felt to be safe at 8-12 hours for low- and intermediate-risk chest pain patients who have normal baseline EKGs and capacity to exercise, and are not taking digoxin.

Ischemia induced during stress protocols for echocardiography or myocardial perfusion imaging (MPI) indicates impaired coronary perfusion in the face of increased oxygen demand. MPI also can be used to detect rest ischemia indicating impaired regional myocardial perfusion, a hallmark of the ACS.

Both stress echocardiography (sensitivity: 86%; specificity: 81%) and MPI (87%; 73%) are more effective in detecting coronary artery disease than exercise treadmill testing (70%; 75%). However, while MPI is an effective test, it is associated with considerable radiation exposure.

Use of pharmacologic agents can be substituted for exercise in patients unable to exercise according to modified Bruce protocols. Dobutamine increases myocardial demand. Vasodilators such as adenosine, dipyridamole, and regadenoson simulate exercise stress conditions by dilating coronary arteries and creating maldistribution of myocardial perfusion.

A major clinical trial is ongoing to assess the value of CT coronary arteriography, which has a very high negative predictive value, in assessing chest pain syndrome patients in the ED.

As many as 20%-25% of patients with negative chest pain unit evaluations present again for similar evaluations.

Implementation

The goal of ED evaluation of chest pain is the exclusion of ACS and other urgent conditions as appropriate diagnoses. Assessment of the presence of coronary artery disease is best handled in other settings. Experience with chest pain units and accelerated diagnostic protocols have provided effective evidence-based strategies for triaging these patients.

While classic anginal symptoms can aid in the evaluation of acute chest pain, ACS patients can present with atypical or confusing complaints and require care assessment by evaluating health professionals. Nausea and diaphoresis associated with severe chest pain are highly associated with acute ischemia, but elderly patients may have predominantly respiratory complaints.

Patients with sudden-onset, severe chest pain should be considered for pneumothorax, pulmonary embolus, or aortic dissection.

Patients at low risk for myocardial infarction (less than 5%) should be identified by current symptoms, past history, and a new electrocardiogram. These patients have normal EKGs, normal initial cardiac injury lab findings, and stable hemodynamics and cardiac rhythm. The Thrombolysis in Myocardial Infarction (TIMI) risk score is widely used, but has not performed consistently for low-risk populations.

Patients with acute ST segment elevation frequently have near-total or total coronary occlusion and are candidates for reperfusion interventions.

Patients who present during the first 6 hours of chest pain onset and who have negative cardiac markers should be retested after 8 hours to validate the negative results. Newer assays of troponin have good sensitivity and specificity, and are preferred over creatine kinase MB and myoglobin measurement. Laboratories should return results within an hour of specimen sampling or else point-of-service assessment should be considered. B-type natriuretic peptide, while useful for congestive heart failure evaluation, does not offer value in the assessment of acute ischemia.

For patients with indeterminant initial presentations, chest pain protocols can help structure observation. Exercise stress testing is optional in patients with cocaine-related chest pain after a negative period of observation and testing.

Patients who have no additional chest discomfort, undiagnostic initial and follow-up EKGs, and negative injury lab values can be discharged without stress testing for outpatient follow-up investigations.

Repeat treadmill stress testing has limited value in patients with a previous negative evaluation for chest pain in an emergency setting. These patients may eventually require coronary arteriography as negative cardiac caths, in comparison to noninvasive evaluation, reduce repeat ED chest pain evaluations by more than 50%.

Reference

Amsterdam EA et al. Testing of Low-Risk Patients Presenting to the Emergency Department with Chest Pain (Circulation 2010;122:756-76).

This column, "The Effective Physician," appears regularly in Internal Medicine News, an Elsevier publication. Dr. Golden is professor of medicine and public health and Dr. Hopkins is program director for the internal medicine/pediatrics combined residency program at the University of Arkansas, Little Rock.