Chiefs’ Inquiry Corner – 11/10/2021

November 10, 2021

Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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 The mass effect of a gravid uterus impacts numerous aspects of a pregnant woman’s anatomy. The resting position of the diaphragm shifts up by about 5 cm, and lung volumes undergo a number of changes to maintain a stable total lung capacity. The hormone progesterone stimulates respiration, so there is baseline hyperventilation with the PaCO2 decreasing on average to around 30, with a subsequent respiratory alkalosis. These factors can be important to keep in mind, as we have to recognize a new baseline normal state in order to be vigilant for changes that could indicate abnormal pathology.

References: Physiology, Maternal Changes
 Patients with PAD are dramatically undertreated compared to their CAD counterparts, and there is significantly less research on efficacy of our treatment options. The ACC/AHA recommend that all patients with symptomatic PAD are placed on a high intensity statin. Patients with PAD plus another major atherosclerotic cardiovascular disease event should be treated to an LDL-C level of less than 70. These high-risk patients may benefit from the addition of Zetia to a statin if this target is unable to be met on statin monotherapy. PAD is also associated with platelet hyperaggregability, and in patients with symptomatic PAD there is a role for aspirin in preventing major cardiovascular events. The Clopidogrel Versus Aspirin in Patients at Risk for Ischemic Events (CAPRIE) trial subanalysis actually suggested Clopidogrel may be superior, but the ACC/AHA guidelines have not distinguished the type of antiplatelet therapy recommended. Though commonly tested on the medicine boards, Cilostazol is rarely used in medical practice due to its contraindication in patients with heart failure, as well as its common side effects. Blood pressure management, exercise therapy, and smoking cessation all play a key role in addition to considering pharmacotherapy. Smoking cessation is the greatest modifiable risk factor for development and progression of PAD.

References: Evidence-Based Medical Management of Peripheral Artery Disease
 The prevalence of inpatient hypertension may be as high as 72%, and many guidelines are focused on management of chronic hypertension in the outpatient, ambulatory setting rather than for hospitalized patients. One study examined older adults > 65 years being discharged from a VA Hospital with either a new blood pressure medication or a higher dose than their home medication. They found that patients who had intensification in either manner had higher risk of hospital readmission (NNH 27) as well as other serious adverse events (NNH 63), including falls, hypotension, acute kidney injury, and electrolyte abnormalities. At 1 year, they did not find a difference in cardiovascular events.

References: Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge