Chiefs’ Inquiry Corner – 12/13/2021

December 14, 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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      Beta-blockers are not indicated for the general treatment of hypertension unless ischemic heart disease or heart failure is present. However, cardioselective beta blockers (such as metoprolol succinate and bisoprolol) confer a survival benefit in people with hypertension and concurrent heart failure or recent myocardial infarction. There is often hesitation to use beta blockers in people with reactive airway disease such as COPD due to concerns of precipitating or worsening bronchospasm. In fact, cardioselective beta blockers are substantially underused in people with COPD who also have heart failure or coronary artery disease; only about half of patients in three studies examined received cardioselective beta blockers, even when treatment with these agents was indicated. However, use of cardioselective agents in patients with COPD and comorbidities with indications for beta blockade should be strongly considered if a survival benefit from beta blockade has been established. With low initial dose and cautious uptitration of dose, cardioselective beta blockers can be used safely in people with pulmonary disease. That being said, the use of noncardioselective beta-blockers (such as carvedilol or propranolol) should not be used to treat any condition in someone with reactive airway disease.

References: Treating Hypertension in Chronic Obstructive Pulmonary Disease
 In March 2021, the United States Preventive Services Task Force (USPSTF) released updated recommendations for lung cancer screening in adults. USPSTF now recommends yearly screening for lung cancer with low-dose computer tomography in adults aged 50-80 years who have a 20 pack-year smoking history and currently smoke or have quit smoking in the last 15 years. This newest iteration of recommendations expands the age range for screening from 55-80 years to 50-80 years, and decreases the pack-year history required for screening (previously 30 pack-years, now 20 pack years). As always, the decision to undergo screening is a shared one with patients, and should involve a discussion of potential benefits, limitations, and harms. For those who qualify and opt for yearly screening, screening can be discontinued when the person turns 81, has not smoked for 15 years, or has a health problem that would limit life expectancy and/or ability or willingness to have lung surgery, whichever occurs first.

References:  US Preventive Services Task Force Final Recommendations: Lung Cancer Screening
 Among all viruses both hepatotropic and nonhepatotropic, hepatitis C virus is recognized as the virus most associated with extrahepatic manifestations. These manifestations include cryoglobulinemic vasculitis, B-cell lymphoma, cardiovascular disease, DM2, and chronic kidney disease. The underlying pathophysiology leading to these conditions is diverse and complex, but includes downstream effects of chronic inflammation, direct cytopathic injury, and disruptions of hormonal and immune signaling pathways, as well as potentially direct viral mechanisms. Importantly, there is an established relationship between treatment-induced, sustained viral clearance and reduction in incidence and severity of extrahepatic manifestations of HCV infection. While not all extrahepatic manifestations of HCV may be reversible even after treatment (for example, neuropathic pain from cryoglobulinemic vasculitis can persist after HCV treatment, but this is due to previously rendered vascular damage rather than active, ongoing inflammation), improvement and/or stabilization of symptoms is yet another compelling reason to increase detection and treatment of hepatitis C in at-risk populations.

References: Extrahepatic Manifestations of Chronic HCV Infection