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.

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.

Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).

This chapter about antithrombotic therapy in atrial fibrillation (AF) is part of the American College of Chest Physicians Evidence-Based Guidelines Clinical Practice Guidelines (8th Edition). Grade 1 recommendations indicate that most patients would make the same choice and Grade 2 suggests that individual patient's values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2008; 133[suppl]:123S-131S). Among the key recommendations in this chapter are the following (all vitamin K antagonist [VKA] recommendations have a target international normalized ratio [INR] of 2.5; range 2.0-3.0, unless otherwise noted). In patients with AF, including those with paroxysmal AF, who have had a prior ischemic stroke, transient ischemic attack (TIA), or systemic embolism, we recommend long-term anticoagulation with an oral VKA, such as warfarin, because of the high risk of future ischemic stroke faced by this set of patients (Grade 1A). In patients with AF, including those with paroxysmal AF, who have two or more of the risk factors for future ischemic stroke listed immediately below, we recommend long-term anticoagulation with an oral VKA (Grade 1A). Two or more of the following risk factors apply: age >75 years, history of hypertension, diabetes mellitus, moderately or severely impaired left ventricular systolic function and/or heart failure. In patients with AF, including those with paroxysmal AF, with only one of the risk factors listed immediately above, we recommend long-term antithrombotic therapy (Grade 1A), either as anticoagulation with an oral VKA, such as warfarin (Grade 1A), or as aspirin, at a dose of 75-325 mg/d (Grade 1B). In these patients at intermediate risk of ischemic stroke we suggest a VKA rather than aspirin (Grade 2A). In patients with AF, including those with paroxysmal AF, age < or =75 years and with none of the other risk factors listed above, we recommend long-term aspirin therapy at a dose of 75-325 mg/d (Grade 1B), because of their low risk of ischemic stroke. For patients with atrial flutter, we recommend that antithrombotic therapy decisions follow the same risk-based recommendations as for AF (Grade 1C). For patients with AF and mitral stenosis, we recommend long-term anticoagulation with an oral VKA (Grade 1B). For patients with AF and prosthetic heart valves we recommend long-term anticoagulation with an oral VKA at an intensity appropriate for the specific type of prosthesis (Grade 1B). See CHEST 2008; 133(suppl):593S-629S. For patients with AF of > or =48 h or of unknown duration for whom pharmacologic or electrical cardioversion is planned, we recommend anticoagulation with an oral VKA, such as warfarin, for 3 weeks before elective cardioversion and for at least 4 weeks after sinus rhythm has been maintained (Grade 1C). For patients with AF of > or = 48 h or of unknown duration undergoing pharmacological or electrical cardioversion, we also recommend either immediate anticoagulation with unfractionated IV heparin, or low-molecular-weight heparin (LMWH), or at least 5 days of warfarin by the time of cardioversion (achieving an INR of 2.0-3.0) as well as a screening multiplane transesophageal echocardiography (TEE). If no thrombus is seen, cardioversion is successful, and sinus rhythm is maintained, we recommend anticoagulation for at least 4 weeks. If a thrombus is seen on TEE, then cardioversion should be postponed and anticoagulation should be continued indefinitely. We recommend obtaining a repeat TEE before attempting later cardioversion (Grade 1B addressing the equivalence of TEE-guided vs non-TEE-guided cardioversion). For patients with AF of known duration <48 h, we suggest cardioversion without prolonged anticoagulation (Grade 2C). However, in patients without contraindications to anticoagulation, we suggest beginning IV heparin or LMWH at presentation (Grade 2C).

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.

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.

Silent Atrial Fibrillation and Cryptogenic Strokes.

A new suspected cause of cryptic strokes is "silent atrial fibrillation." Pacemakers and other implanted devices allow continuous recording of cardiac rhythm for months or years. They have discovered that short periods of atrial fibrillation lasting minutes or hours are frequent and usually are asymptomatic. A meta-analysis of 50 studies involving more than 10,000 patients with a recent stroke found that 7.7% had new atrial fibrillation on their admitting electrocardiogram. In 3 weeks during and after hospitalization, another 16.9% were diagnosed. A total of 23.7% of these stroke patients had silent atrial fibrillation; that is, atrial fibrillation diagnosed after hospital admission. Silent atrial fibrillation is also frequent in patients with pacemakers who do not have a recent stroke. In a pooled analysis of 3 studies involving more than 10,000 patients monitored for 24 months, 43% had at least 1 day with atrial fibrillation lasting more than 5 minutes. Ten percent had atrial fibrillation lasting at least 12 hours. Despite the frequency of silent atrial fibrillation in these patients with multiple risk factors for stroke, the annual incidence of stroke was only 0.23%. When silent atrial fibrillation is detected in patients with recent cryptogenic stroke, anticoagulation is indicated. In patients without stroke, silent atrial fibrillation should lead to further monitoring for clinical atrial fibrillation rather than immediate anticoagulation, as some have advocated.

Opposition to Obamacare: A Closer Look.

Prior telephone surveys have reported two main reasons for opposition to the Affordable Care Act (ACA): distrust of government and opposition to the universal coverage mandate. The authors set out to elucidate the reasons for this opposition. This article describes how the authors used qualitative methods with semistructured interviewing as a principal investigative method to gather information from people they met while bicycling across the United States from April through July 2016. During this time, the authors conducted open-ended, semistructured conversations with people they met as they rode their bicycles from Washington, DC, to Seattle, Washington. Informants were chosen as a convenience sample. One hundred sixteen individuals participated as informants. The majority of comments were negative toward the ACA. Conversations were categorized into four themes, which included the following: (1) The ACA has increased the cost of health insurance; (2) government should not tell people what to do; (3) responsibility for ACA problems is diffuse; and (4) the ACA should not pay for other people's problems. These face-to-face conversations indicated that opposition to the ACA may be due to the fact that many Americans have experienced an increase in the cost of insurance either through increased premiums or greatly increased deductibles. They blame this increase in cost on the ACA, President Obama, the government or insurance companies, and the inclusion of "others" in insurance plans. The authors discuss how these findings can influence medical education curricula to better prepare future physicians to discuss health policy issues with patients.

Pulmonary Embolism with Right Ventricular Dysfunction: Who Should Receive Thrombolytic Agents?

BACKGROUND: Appropriate management of pulmonary embolism patients with right ventricular dysfunction is uncertain. Recent guidelines have stressed the need for more data on the use of thrombolytic agents in the stable pulmonary embolism patient with right ventricular dysfunction. The objective of this study is to investigate the hypothesis that thrombolytic therapy in hemodynamically stable pulmonary embolism patients with right ventricular dysfunction is not associated with improved mortality. METHODS: We did a retrospective analysis using multi-institutional observational data from the Nationwide Inpatient Sample database. International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes were used to identify the patients with pulmonary embolism and right ventricular dysfunction. In-hospital mortality was defined as the primary outcome of interest. RESULTS: Over the 4 years of the study period, 3668 patients with right ventricular dysfunction and pulmonary embolism were found, of which 3253 patients were identified as having hemodynamically stable right-sided heart failure with pulmonary embolism. There was no significant difference in mortality between hemodynamically stable pulmonary embolism patients with right ventricular dysfunction who received thrombolytic agents compared with those who did not. When outcomes were assessed for patients with right ventricular dysfunction and hemodynamic instability, a significant improvement in mortality was noted for patients with right ventricular dysfunction who received thrombolytic agents, which confirmed previous reports that thrombolytic therapy decreases mortality in pulmonary embolism patients who are hemodynamically unstable. CONCLUSION: Our data support the use of less aggressive treatment for stable pulmonary embolism patients with right ventricular dysfunction. These results argue against the reflexive use of thrombolytic agents in stable pulmonary embolism patients with right ventricular dysfunction.

Cryptogenic Strokes and Patent Foramen Ovales: What's the Right Treatment?

More than 25% of all ischemic strokes per year are cryptogenic, that is, their cause is not determined after an appropriate evaluation. In 1988, it was reported that the incidence of a patent foramen ovale was 30 to 40% in young patients with a cryptogenic stroke compared with 25% in the general population. This led to the suspicion that cryptogenic strokes were due to paradoxical embolism, that is, a venous thrombus crossing a patent foramen ovale to enter the left atrium and then the arterial circulation. Few of the patients considered to have paradoxical embolism were shown to have coexistent venous thromboembolism. This suspicion of paradoxical embolism led to thousands of patients undergoing surgical closure of their patent foramen ovale. Surgical closure was replaced by closure of the patent foramen ovale by a variety of transvenous devices. Others recommended anticoagulant or antiplatelet therapy to prevent recurrent ischemic strokes. Three randomized clinical trials totaling more than 2000 patients compared closure of the patent foramen ovale with medical therapy. All 3 trials reported that closure of the patent foramen ovale provided no benefit compared with medical therapy. Subsequent trials have demonstrated no benefit of anticoagulation compared with antiplatelet therapy in patients with cryptogenic strokes with or without a patent foramen ovale. Patients with cryptogenic strokes should be evaluated for the presence of venous thromboembolism. If venous thromboembolism is present, treatment should be the same as for pulmonary embolism: anticoagulation. If venous thromboembolism is not present, antiplatelet therapy is indicated.

Clinicians' responses to direct-to-consumer advertising of prescription medications.

BACKGROUND: The direct-to-consumer advertising (DTCA) of prescription medications is proliferating in the United States. The relationship between patient exposure to DTCA and the response of clinicians is not well understood. METHODS: A randomized postal survey of Arizona primary care provider physicians (n = 1080) and physician assistants (n = 704) was conducted. A questionnaire was created using a hypothetical patient scenario that varied according to the diagnosis of the patient (ie, hypertension, hypercholesterolemia, seasonal allergies, or obesity) and the type of informational exposure generating the patient's questions (ie, DTCA vs drug references such as Physicians' Desk Reference). Clinicians were randomly assigned 1 of 8 forms of the scenario and were asked standardized questions related to their responses when faced with the patient scenario. RESULTS: The response rate was 44% (40.5% of physicians and 49.3% of physician assistants). No statistically significant differences were found between the early and late responders or between responders and nonresponders. Relative to clinicians who received the "drug reference book" patient scenario, clinicians who received the DTCA patient scenario were more likely to become annoyed with a patient for asking for more information about medications (P =.003); less likely to answer the patient's questions (P =.03) or provide additional written information (P =.007); more likely to become frustrated (P =.003) and annoyed (P<.001) with the patient for asking to try a specific medication; and less likely to provide samples (P =.001) or a prescription (P<.001) for a specific medication. CONCLUSION: Clinicians are amenable to patients asking for drug information and medications, but they are less receptive to questions arising from DTCA.

Why do so many Americans oppose the Affordable Care Act?

The Patient Protection and Affordable Care Act (ACA) was passed by a Democratic Congress and signed into law by a Democratic president in 2010. Republican congressmen, governors, and Republican candidates have consistently opposed the ACA and have vowed to repeal it. Polls have consistently shown that it is supported by <50% of Americans. The most important goal of the ACA is to improve the health of Americans by increasing the number covered by health insurance. In the first year of its implementation, more than 10 million citizens gained health insurance. The percentage of Americans without health insurance decreased from 18% in July 2013 to 13.4% in June 2014. In addition, the ACA has eliminated many of the negative features of private insurance such as the denial of coverage for those with "prior conditions." The benefits of Medicare have been enhanced to decrease the cost of prescription drugs and to eliminate co-pays for preventive services. Despite these positive changes, a near majority of Americans still oppose the ACA, even though they approve of most of its features. They oppose the mandate that all Americans must have health insurance (the individual mandate), and they oppose a government role in health care. Yet Medicare, a mandatory insurance for seniors administered by the federal government since 1965, is overwhelmingly approved by the American public. The opposition to a government role in health care is based on the fact that that the vast majority of our citizens do not trust their government. Republicans are much less trusting of the federal government and much less supportive of a government role in health care than Democrats. The overwhelmingly negative TV ads against the ACA by the Republican candidates in the elections of 2012 and 2014 have had a major impact on Americans' views of the ACA. More than 60% of Americans have stated that most of what they know about the ACA came from watching TV. Opposition to a government role in health care and to mandatory health insurance makes it unlikely that the US will be able to insure that all of its citizens have ongoing access to health care in the near future.

A 25-year perspective into the changing landscape of patients hospitalized with acute myocardial infarction (the Worcester Heart Attack Study).

Over the past several decades, significant advances have been made in the primary and secondary prevention of coronary artery disease. However, effects of changing lifestyle and treatment practices on demographic and clinical profiles and on hospital outcomes of patients who present with acute myocardial infarction (AMI) have not been well characterized. We carried out a prospective population-based investigation of >25-year trends (1975 to 2001) in demographic and clinical characteristics, treatment practices, and hospital outcomes of patients who had been hospitalized with AMI. Residents of a metropolitan area (Worcester, Massachusetts) who had been hospitalized with validated AMI (n = 10,440) in all greater Worcester hospitals during thirteen 1-year periods between 1975 and 2001 comprised the sample of interest. Patients who had been hospitalized during the most recent study years were significantly older, were more likely to be women, and had a greater prevalence of co-morbidities. Hospitalized patients were increasingly more likely to receive effective cardiac medications and coronary interventions over the period under investigation. Multivariable-adjusted hospital survival rates improved considerably over time, whereas different trends were observed in the occurrence of several important clinical complications. The present results provide insights into the changing characteristics of patients who are hospitalized with AMI, treatment practices, and their short-term outcomes. Given the magnitude of AMI and evolving approaches to manage it, continued monitoring of these trends remains of considerable clinical and public health importance.

Antithrombotic therapy in patients with saphenous vein and internal mammary artery bypass grafts: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.

This chapter about prevention of coronary artery bypass occlusion is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients undergoing coronary artery bypass grafting (CABG), we recommend aspirin, 75 to 162 mg/d, starting 6 h after operation over preoperative aspirin (Grade 1A). In patients in whom postoperative bleeding prevents the administration of aspirin at 6 h after CABG, we recommend starting aspirin as soon as possible thereafter (Grade 1C). For patients undergoing CABG, we recommend against addition of dipyridamole to aspirin therapy (Grade 1A). For patients with coronary artery disease undergoing CABG who are allergic to aspirin, we recommend clopidogrel, 300 mg, as a loading dose 6 h after operation followed by 75 mg/d p.o. (Grade 1C+). In patients who undergo CABG for non-ST-segment elevation acute coronary syndrome (ACS), we recommend clopidogrel, 75 mg/d for 9 to 12 months following the procedure in addition to treatment with aspirin (Grade 1A). For patients who have received clopidogrel for ACS and are scheduled for CABG, we recommend discontinuing clopidogrel for 5 days prior to the scheduled surgery (Grade 2A). For patients undergoing CABG who have no other indication for vitamin K antagonists (VKAs), we suggest clinicians to not administer VKAs (Grade 2B). For patients undergoing CABG in whom oral anticoagulants are indicated, such as those with heart valve replacement, we suggest clinicians administer VKA in addition to aspirin (Grade 2C). For all patients with coronary artery disease who undergo internal mammary artery (IMA) bypass grafting, we recommend aspirin, 75 to 162 mg/d, indefinitely (Grade 1A). For all patients undergoing IMA bypass grafting without other indication for VKA, we suggest clinicians not use VKA (Grade 2C).

Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.

This chapter about antithrombotic therapy in atrial fibrillation (AF) is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following (all vitamin K antagonist [VKA] recommendations have a target international normalized ratio [INR] of 2.5; range, 2.0 to 3.0): In patients with persistent or paroxysmal AF (PAF) [intermittent AF] at high risk of stroke (ie, having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age > 75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, history of hypertension, or diabetes mellitus), we recommend anticoagulation with an oral VKA, such as warfarin (Grade 1A). In patients with persistent AF or PAF, age 65 to 75 years, in the absence of other risk factors, we recommend antithrombotic therapy with either an oral VKA or aspirin, 325 mg/d, in this group of patients who are at intermediate risk of stroke (Grade 1A). In patients with persistent AF or PAF < 65 years old and with no other risk factors, we recommend aspirin, 325 mg/d (Grade 1B). For patients with AF and mitral stenosis, we recommend anticoagulation with an oral VKA (Grade 1C+). For patients with AF and prosthetic heart valves, we recommend anticoagulation with an oral VKA (Grade 1C+); the target INR may be increased and aspirin added depending on valve type and position, and on patient factors. For patients with AF of > or = 48 h or of unknown duration for whom pharmacologic or electrical cardioversion is planned, we recommend anticoagulation with an oral VKA for 3 weeks before and for at least 4 weeks after successful cardioversion (Grade 1C+). For patients with AF of > or = 48 h or of unknown duration undergoing pharmacologic or electrical cardioversion, an alternative strategy is anticoagulation and screening multiplane transesophageal echocardiography (Grade 1B). If no thrombus is seen and cardioversion is successful, we recommend anticoagulation for at least 4 weeks (Grade 1B). For patients with AF of known duration < 48 h, we suggest cardioversion without anticoagulation (Grade 2C). However, in patients without contraindications to anticoagulation, we suggest beginning IV heparin or low molecular weight heparin at presentation (Grade 2C).