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2 November 2010 Annals of Internal Medicine Tip Sheet

Below is information about three articles being published in the September 21 issue of Annals of Internal Medicine. The information is not intended to substitute for articles as sources of information. Annals of Internal Medicine attribution is required for all coverage. For an embargoed copy of a study, contact Angela Collom at acollom@acponline.org or 215-351-2653.

1. Patient Age May Diminish Death Benefit of Implantable Cardioverter-Defibrillators

Implantable cardioverter-defibrillators (ICD) can prevent sudden cardiac death and reduce mortality from other causes in some patients with severe left ventricular dysfunction. But enthusiasm for ICDs may result in the use of ICDs in some patients who are unlikely to benefit from them. Since ICDs are expensive and invasive, determining which patient populations are most likely to benefit from ICD placement is paramount. Researchers reviewed evidence from published clinical trials to compare the effectiveness of ICD therapy versus standard medical therapy for the primary prevention of sudden cardiac death in different age groups of patients with severe left ventricular dysfunction. The researchers reviewed five articles that included mortality rates for different age ranges of patients that had prophylactic ICD. They found that the benefit of ICDs is related to patient age and the benefit in elderly patients is inconclusive. They suggest further research to guide the appropriate use of ICDs in elderly patients.

2. Pain is Common in Patientsí Final Years, Especially for Those with Arthritis

As patients near death, studies show that controlling pain is an important factor in maintaining good quality of life. While it is believed that pain increases in the last weeks before death, few studies have examined the prevalence of pain at regular intervals throughout the last months of life. Between 1992 and 2004, the Health and Retirement Study (HRS) interviewed a nationally representative sample of community-dwelling older adults every two years about matters concerning their health. Researchers used the HRS data to determine the prevalence of pain during the last years of life. The researchers reviewed survey data for 4,703 patients who died while enrolled in the study and who had completed questions about pain within two years of their death. They found that the prevalence of moderate to severe pain was most common during the four months preceding death. Patients reported similar levels of pain severity across an array of serious illnesses, but patients with arthritis reported substantially more pain than patients without this condition. The researchers conclude that physicians should monitor for presence of pain and attempt to control it as much as possible for patients who may be near death. Pain management may be particularly important for patients with arthritis.

Opinion:

3. E-Cigarettes Present New Challenge for Physicians Counseling Patients to Abstain from Nicotine

Aggressive Internet Marketing Increases Consumer Awareness and Acceptance

Manufacturers market electronic cigarettes to patients trying to quit smoking and to those whose ability to smoke is restricted by anti-smoking laws. Electronic cigarettes (e-cigarettes) aerosolize nicotine and produce a vapor that mimics that of cigarette smoking. Online marketers claim that e-cigarettes have fewer toxins than real cigarettes and donít give off secondhand smoke. However, these safety claims have yet to be thoroughly studied. The authors warn that the e-cigarette boom on the internet may present several public health concerns. First, the safety claims of e-cigarette marketers may encourage nonsmokers to start using. Second, e-cigarettes require refills using concentrated liquid nicotine. If accidentally ingested or absorbed through the skin, the liquid nicotine could cause fatalities, especially in small children. Finally, aggressive affiliate marketing techniques are used to promote e-cigarette use, which could dissuade smokers attempting to quit and even promote relapse. Physicians should be aware of the popularity, questionable efficacy claims, and safety concerns of e-cigarettes so that they may counsel patients to abstain.

Early Release:

4. Dabigatran May be a Cost-effective Alternative to Warfarin for Patients with Atrial Fibrilation

Warfarin has been traditionally used to prevent stroke in patients with atrial fibrillation (AF). Patients taking warfarin require close monitoring and dose-adjustment as over-anticoagulation can occur, resulting in serious or fatal hemorrhage. Recently, dabigatran, a fixed-dose, oral direct thrombin inhibitor, was approved by the FDA to prevent stroke in patients with AF. Dabigatran has similar stroke-reduction benefits to warfarin, but may have a lower rate of hemorrhage. Using a computer model, researchers performed a decision analysis to compare the quality-adjusted survival, costs, and cost-effectiveness of three treatment strategies for the prevention of stroke in patients with AF: adjusted-dose warfarin, a twice daily low dose of dabigatran (110 mg), or a twice daily high dose of dabigatran (150 mg). The researchers found that for patients older than 65 with a high risk for stroke, a high dose of dabigatran was the most effective treatment option and could be a cost-effective alternative to warfarin, depending on drug costs in the United States.