Are Statins Indicated in Senior Citizens? A Review of Statin Therapy in the Elderly.

The use of statin therapy in atherosclerotic cardiovascular disease (ASCVD) has demonstrated substantial improvement in morbidity and mortality of the aging population. Despite exhaustive studies demonstrating the benefits of statin therapy linking lower cholesterol levels to decreased vascular events, statin guidelines vary greatly with age, and recommendations are unclear regarding initiation and discontinuation of statin therapy in patients 65 years and older. Data suggest that statins are highly effective at secondary prevention of major cardiovascular events and development of coronary heart disease in patients with a history of vascular disease or risk factors such as diabetes mellitus, hypertension, hypercholesterolemia, or smoking. Therefore, patients who meet these criteria, regardless of age, should begin statin therapy. There is also some evidence to suggest that statin therapy may be beneficial in primary prevention of major cardiovascular events, although these data are not as well studied as secondary prevention use of statin therapy, and should therefore be individualized for each patient.

Optimal Therapy for Unstable Pulmonary Embolism.

There are no randomized controlled trials of thrombolytic therapy, pulmonary embolectomy, or inferior vena cava (IVC) filters in patients with unstable pulmonary embolism (those in shock or on ventilator support). Yet, there are many investigations of these treatments based on retrospective cohort studies using administrative data from large government and commercial databases. Extensive data from these cohort studies showed that thrombolytic therapy resulted in the lowest in-hospital all-cause mortality. The results of thrombolytic therapy were greatly improved if IVC filters were added. In fact, IVC filters decreased in-hospital all-cause mortality with anticoagulants alone or with pulmonary embolectomy as well as thrombolytic therapy in adults of all ages with unstable pulmonary embolism. The IVC filters reduced mortality only if inserted on the day of admission or the next day, while the patients were unstable and in a fragile condition. We conclude that the best treatment for patients with unstable pulmonary embolism is thrombolytic therapy combined with an IVC filter inserted during the period of fragility, while the patient is unstable, and this treatment is indicated in all unstable patients irrespective of age.

The Significance of Incidental Findings on Computed Tomography of the Chest.

BACKGROUND: Computed tomography (CT) of the chest has replaced lung scans and pulmonary angiography as the criterion standard for the diagnosis of pulmonary embolism (PE). Most of these examinations are negative for PE, but they frequently have incidental findings that may require further evaluation. OBJECTIVE: In order to examine common incidental findings and their possible clinical ramifications and required workup, we reviewed data from relevant studies in which chest CTs were performed and incidental findings discovered. DISCUSSION: The most common incidental findings on chest CT are pulmonary nodules and lymph nodes. Nodules are significantly more commonly found in smokers and are also more likely to be malignant in smokers. The recently updated 2017 Fleischner Society recommendations provide guidance to clinicians in deciding which nodules should be further evaluated. Enlarged lymph nodes similarly represent potential malignancy and most will need further evaluation with positron emission tomography scans or by transbronchial needle aspiration. CONCLUSIONS: Enlarged lymph nodes and pulmonary nodules are both common incidental findings on chest CT. Each represents the potential for malignancy, and under certain conditions requires additional workup and further evaluation. The majority will be benign, even in high-risk populations. However, because of the increasing prevalence of the chest CT and the frequency with which incidental findings will be seen, it is important that the emergency physician be aware of common features and recommended subsequent evaluation.

Cardiac Cath Labs: Their Origins and Their Future.

More than 1 million diagnostic cardiac catheterizations (excluding percutaneous coronary intervention-only procedures) are performed each year in the nearly 2,000 cardiac catheterization laboratories in the United States.1.

Which Patent Foramen Ovales Need Closure to Prevent Cryptogenic Strokes?

Patients with cryptogenic strokes are more likely to have a patent foremen ovale than in the general population. It is speculated that these strokes are due to paradoxical embolism, that is, passage of a venous thrombus across the patent foremen ovale to enter the arterial circulation, resulting in an embolic stroke. Venous thromboembolism is rarely present in these cases of cryptogenic stroke. Thousands of patients with cryptogenic strokes have undergone transcatheter closure of their patent foremen ovale via a variety of devices. The first 3 randomized clinical trials comparing patent foremen ovale closure with medical therapy failed to show a significant advantage of patent foremen ovale closure. Three additional trials reported in 2017 had longer years of follow-up and demonstrated an advantage of patent foremen ovale closure versus medical therapy. Analysis of their data indicated that patent foremen ovale closure in patients with an atrial septal aneurysm in addition to a patent foremen ovale had a very significant decrease in cryptogenic strokes (P < .001). There was no decrease in strokes in patients without an aneurysm of the atrial septum who underwent patent foremen ovale closure (P = .37). Aneurysms of the atrial septum are easily recognized by echocardiography and are present in approximately one-third of patients with patent foremen ovales. These data suggest that closure of patent foremen ovales in patients with an atrial septal aneurysm is indicated. In patients with a patent foremen ovale without an aneurysm of the atrial septum, patent foremen ovale closure is not indicated.