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Treating Anemia in Heart Disease Patients

Treating Anemia in Heart Disease Patients

Studies indicate that anemia occurs in about one-third of patients with congestive heart failure and up to 20% of those with coronary heart disease (CHD). The condition has been linked to an increased risk for hospitalizations, decreases in exercise capacity, a poorer quality of life, and higher mortality. The risks and benefits of treating anemia in patients with heart disease are important to understand. Providing Guidance In the Annals of Internal Medicine, the American College of Physicians (ACP) published guidelines that presented the current evidence and provided clinical recommendations on the treatment of anemia and iron deficiency in adults with heart disease. The guideline was based on a review of the literature on anemia and iron deficiency published from 1947 to 2013. The first recommendation made in the guideline was to use a restrictive red blood cell transfusion strategy (trigger hemoglobin threshold of 7 to 8 g/dL, compared with a higher hemoglobin level) in hospitalized patients with CHD. “When compared with a restrictive transfusion strategy, there is low-quality evidence that showed no benefit of using a liberal transfusion strategy in which the trigger threshold for hemoglobin levels was greater than 10 g/dL,” says Amir Qaseem, MD, PhD, who was lead author of the ACP guideline. “This strategy will likely be a slight shift from the aggressive approaches clinicians have used in the past.” ACP also recommends against the use of erythropoiesis-stimulating agents (ESAs) in patients with mild-to-moderate anemia and congestive heart failure or CHD. “This is a strong recommendation that was made on moderate-quality evidence,” says Dr. Qaseem. “We found that the harms of treating patients with mild-to-moderate anemia...
Guidance for PCI Without On-Site Surgical Backup

Guidance for PCI Without On-Site Surgical Backup

In 2007, the Society for Cardiovascular Angiography and Interventions (SCAI) published an expert consensus document on the current status and future direction of PCI without on-site surgical backup. The document reviewed the existing literature and examined recommendations for performing PCI in this setting from several existing programs and other sources, thereby defining best practices for facilities and operators. “Since that time, new studies, meta-analyses, and randomized trials have been published in which PCI with and without on-site surgery has been compared,” says Gregory J. Dehmer, MD, FACC, FACP, FSCAI. “In addition, professional organizations have published appropriate use criteria for coronary revascularization and other documents affecting the practice of PCI.” According to Dr. Dehmer, several noteworthy changes occurred in PCI guidelines that were released in 2011. “Elective PCI was upgraded to Class IIb, and primary PCI was upgraded to Class IIa at facilities without on-site surgery,” he says. In addition to the PCI guidelines, expert consensus documents and competency documents related to PCI plus additional research have provided more information on ways to optimize the structure and operation of PCI programs without on-site surgery. Consolidating Recommendations In 2014, SCAI—in collaboration with the American College of Cardiology and the American Heart Association—released a new expert consensus document on PCI at sites without on-site surgical backup. This document consolidates the myriad of recommendations that have been released in different forms since the 2007 document. “The recommendations are designed to improve safety while maintaining access to quality care,” says Dr. Dehmer, who was lead author of both the 2007 and 2014 consensus documents. As cited in the new document, 11 original studies and...

Drug Wars in the Exam Room

As physicians, we have all been faced with patients inappropriately looking for prescriptions for controlled substances. Some are looking to abuse them and some to divert them for profit. It is often hard to distinguish when a patient truly needs these medications or when they are just “drug-seeking.” More experienced doctors have a better sense of which patients are which. Drug-seeking patients often play on our emotions because they know we generally care about patients and may have difficulty turning down a request for opioids from someone in supposed pain. For years, patients have used many ruses to access these medications. Many of them “doctor shop,” use several pharmacies, or frequent various emergency rooms, making it difficult to track their prescriptions. And it’s much harder for a doctor to turn down a request from a new patient in acute pain than from one the doctor knows well and doubts. Having so many controlled substances available and sold on the streets has led to an increase in prescription drug dependency. These patients have a hard time breaking these addictions and often can only stop with help from special rehab programs. It has led to a further resurgence of IV heroin addiction and opioid deaths in many areas. As the states have tightened controlled substance prescriptions, they have become less available for diversion and are now a gateway drug to heroin—which is cheaper than prescribed medications. I am seeing teens in my practice addicted to IV heroin, a habit that started by raiding parents’ or relatives’ medicine cabinets. It has never been more imperative for doctors to step up and do...
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