Chiefs’ Inquiry Corner – 1/6/19

January 6, 2020

Being an outstanding physician and lifelong learner requires stoking the flames of clinical curiosity.  In Chiefs’ Inquiry Corner (CIC) we attempt to succinctly answer actual clinical questions that have been raised on the wards and in the clinics of NYU’s teaching hospitals.  Our answers are not meant to be all encompassing or practice changing but rather to serve as springboards for further exploration. For those of us with short attention spans, we hope CIC satisfies that craving for a morsel of knowledge in a digestible format.


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Direct oral anticoagulants (DOACs) have replaced warfarin for many indications because they are effective and easier to use. Antiphospholipid syndrome is a notable exception to this trend. In a trial of 120 high risk patients with antiphospholipid syndrome randomized to rivaroxaban versus warfarin, patients in the rivaroxaban arm had higher rates of the primary outcome (thromboembolic events, major bleeding, or death) compared to patients in the warfarin arm (22% versus 3%), and higher rates of thromboembolic events (a secondary outcome) as well (12% versus 0%). As such, it is recommended that patients suspected of having antiphospholipid syndrome should preferentially be prescribed warfarin over DOACs.
The Statin-Associated Muscle Symptoms Clinical Index (SAMS-CI) is a clinical tool that can be used in patients with muscle symptoms that are new or worsening after starting a statin. The score incorporates location and pattern of muscle symptoms, timing of symptom onset relative to statin initiation, timing of symptom improvement after stopping the statin, and (if applicable) symptoms with statin rechallenge. The recently revised scoring system now uses a lower cut off that provides a negative predictive value of >90%, suggesting that SAMS-CI may be an effective tool to exclude SAMS in patients expressing related concerns after being started on a statin. Prospective validation studies of SAMS-CI are in progress.

Atrial fibrillation (a fib) is common in patients with Wolff Parkinson White (WPW), a congenital syndrome involving abnormal myocardial conduction tissue that creates an accessory pathway, leading to “pre-excitation” of ventricular tissue and reentrant tachycardias. The QRS complexes in a fib with pre-excitation may appear wide and therefore may be misinterpreted as ventricular in origin. It is important to avoid AV nodal blockers, including IV amiodarone and IV digoxin in these patients. AV nodal blockade may enhance conduction through the accessory pathway or cause a secondary catecholamine surge, both of which increase the risk of degeneration into ventricular fibrillation. 

References: SVT Guidelines