Chief’s Inquiry Corner 10/27/22

October 27, 2022

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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 Acute decompensated heart failure is traditionally treated with loop diuretics. Recent observational data suggest that low doses of acetazolamide, an inhibitor of carbonic anhydrase in the proximal tubule, given with a loop diuretic, can help increase urinary sodium excretion (a potential measure of diuretic efficiency). A recent clinical trial set out to answer the question of whether acetazolamide improves diuresis and decongestion in patients with acute decompensated heart failure. The Acetazolamide in Decompensated Heart Failure with Volume Overload (ADVOR) trial was a multicenter, randomized, double-blind study that randomized patients to receive an IV bolus of acetazolamide (500mg) for 3 days (or until decongestion) after administration with IV loop diuretics, or placebo with loop diuretics. The primary endpoint was successful decongestion, defined as the absence of clinical signs of volume overload. Secondary endpoints were death or re-hospitalization after 3 months, as well as the duration of hospital admission. In this trial, patients who received acetazolamide saw a more pronounced decrease in congestion within 3 days (number needed to treat of 6). These patients also had decreased lengths of stay and did not suffer an increase in major adverse events. While further work must be done, this trial suggests the potential use of acetazolamide to treat volume overload in acute decompensated heart failure.

References: Acetazolamide in Heart Failure
 A diagnosis of GERD is associated with up to a 15% lifetime risk of Barrett’s esophagus. Barret’s is defined as metaplasia of normal squamous epithelium to columnar. Diagnosis is made via endoscopic biopsy. According to the American College of Gastroenterology, screening for patients with GERD should be based on risk factors associated with its incidence. These include: 1) chronic GERD symptoms for over 5 years, 2) age >50, 3) male sex, 4) tobacco use, 5) central obesity, and 6) Caucasian race. Interestingly, alcohol consumption is not associated with increased risk, and in fact, data suggest a possible protective effect of wine consumption for unclear reasons (possibly due to the antioxidants). Based on these, screening is recommended for men with chronic symptoms (>5 years), with 2 or more of the above risk factors. Screening for Barret’s in females is not recommended, given the lower risk, and should be considered only on a case-by-case basis.

References: Barrett’s Esophagus
 Aspiration pneumonia is thought to account for between 5-15% of community-acquired pneumonia. Guidelines for the treatment of this condition have evolved. In the early 1970s, studies showed that most pathogens isolated from aspiration pneumonia were anaerobes. Thus antibiotics with anaerobic coverage were typically utilized. However, recent data suggest that there has been a shift to bacteria that are more commonly associated with community-acquired pneumonia, such as Streptococcus Pneumonaie and Haemophilus influenzae. Because anaerobes are rarely identified and thus less common in aspiration events than previously thought, recommended treatment regimens have also shifted. In the inpatient setting, the American Thoracic Society and Infectious Diseases Society of America recommend targeting regular community-acquired pathogens. They do not recommend routine use of anaerobic coverage in patients without evidence of lung abscess, empyema, or a post-obstructive process.

References: Aspiration Pneuomonia