Annals
Established in 1927 by the American College of Physicians

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20 November 2012 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 215-351-2653 or e-mail Angela Collom at acollom@acponline.org

1. Six organizations issue new clinical recommendations for diagnosing and treating stable ischemic heart disease

Angina often a symptom of stable IHD

Six organizations representing physicians, other health care professionals, and patients issued two new clinical practice guidelines for diagnosing and treating stable ischemic heart disease (IHD), which affects an estimated one in three adults in the United States. The American College of Physicians, the American Association for Thoracic Surgery, the American College of Cardiology Foundation, the American Heart Association, the Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons collaborated to create the guidelines. Recommendations for evaluating patients with stable IHD address testing for patients who may or may not be able to exercise. Angina -- chest pain or discomfort occurring in an area of the heart that does not get enough blood -- is often a symptom of stable IHD. The organizations recommend that patients with chest pain should receive a thorough history and physical examination to assess the probability of stable IHD prior to additional testing. Choices regarding diagnostic and therapeutic options should be made through a process of shared decision making between the patient and physician to discuss the risks, benefits, and costs to the patient. Recommendations for management of patients with stable IHD address patient education, risk factor modification, medical therapy to prevent myocardial infarction and death, medical therapy and alternative therapy for relief of symptoms, revascularization, and patient follow-up. The guidelines are being published in Annals of Internal Medicine. The Journal of the American College of Cardiology is simultaneously publishing a longer version of the guidelines as one document.

2. Adding Testosterone to Sildenafil Therapy Does Not Improve Erectile Response in Men with Low Testosterone and Erectile Dysfunction

Testosterone replacement added to sildenafil therapy is no better than sildenafil plus placebo at improving erectile function in men with erectile dysfunction (ED) and low testosterone. Approximately one in three men over the age of 50 suffers from ED and many of them also have low testosterone. Researchers randomly assigned 140 men with ED and low testosterone between the ages of 40 and 70 to either 14 weeks of sildenafil plus 10-g of daily transdermal testosterone gel or sildenafil plus placebo to determine whether the addition of testosterone to dose-optimized sildenafil therapy would improve erectile function. All participants had similar erectile function at baseline. Sildenafil alone was associated with a substantial increase in erectile function. Adding testosterone or placebo had no effect on erectile function and adverse events were similar for both groups. The authors note that while testosterone added to sildenafil may not improve erectile function, it may have other benefits such as improved body composition, muscle strength, physical cognition, and metabolism, although these outcomes were not investigated.

3. Task Force Reviews Evidence to Update HIV Screening Recommendations for Adults and Adolescents and Pregnant Women

Draft Recommendations on HIV Screening in Adults and Adolescents and Draft Recommendations on HIV Screening in Pregnant Women will be posted to www.uspreventiveservicestaskforce.org on November 20.

HIV Screening in Adults and Adolescents
In 2005, the United States Preventive Services Task Force recommended that doctors offer HIV screening to all adults and adolescents at increased risk for infection*. For patients with no risk factors, the Task Force recommended that doctors discuss the benefits and harms of testing. Since then, the Task Force reviewed the literature for new studies, specifically those focusing on key research gaps identified in the earlier review. A key difference since 2005 is that researchers reviewed the data to assess the benefits and harms associated with universal screening. The reviewers sought to determine the effect of screening, counseling, and antiretroviral therapy (ART) use on transmission risk; effectiveness of ART for HIV-infected persons with immunologically advanced disease; and long-term harms of ART. The Task Force found no direct evidence that screening for HIV infection improves clinical outcomes versus no screening, but found that targeted screening misses a substantial number of cases due to undisclosed or unknown risk factors. They also found that HIV screening tests are accurate and that identifying undiagnosed HIV infection and treating immunologically advanced disease are associated with substantial clinical benefits. The evidence suggests that the use of ART reduces sexual transmission of HIV and the risk for AIDS-defining events and death in persons with less immunologically advanced stages of disease. This evidence will inform an update to the Task Force’s 2005 recommendations on HIV screening in adults and adolescents. A draft of the recommendations will be posted to www.uspreventiveservicestaskforce.org on November 20.

*Risk factors for HIV that were included in the 2005 recommendation include men or women having a blood transfusion from 1978 to 1985; men or women having unprotected sex with multiple partners; men who have had sex with men after 1975; men and women who have exchanged sex for money or drugs, or who have sex partners who have done so; men or women whose past or present sex partners were HIV-infected, bisexual, or intravenous drug users; and men or women with other sexually transmitted diseases.

HIV Screening in Pregnant Women
In 2005, the United States Preventive Services Task Force recommended that all pregnant women receive HIV screening at their initial prenatal visit unless they specifically decline testing. Since then, the Task Force reviewed published literature for new evidence and studies that could fill information gaps in the research. The researchers sought to determine the benefits and harms of prenatal HIV screening on maternal or child morbidity, mortality, or quality of life, and the effect of screening on mother-to-child transmission. They also looked at benefits and harms of newer antiretroviral therapy (ART) regimens on reducing transmission, and improving long-term maternal morbidity, mortality, and quality of life. The researchers found that HIV tests in pregnant women are accurate, but there was no direct evidence on the effect of screening on mother-to-child transmission or maternal or infant clinical outcomes. The use of ART in combination with avoidance of breastfeeding and elective cesarean section in women with HIV was found to be effective at reducing risk for mother-to-child transmission. Use of certain ART regimens during pregnancy may be associated with increased risk for preterm labor, but short- and long-term effects to mother and infant are not fully known. This evidence will inform an update to the Task Force’s 2005 recommendations on HIV screening in pregnant women. A draft of the recommendations will be posted to www.uspreventiveservicestaskforce.org on November 20.