ACP’s Internal Medicine 2013
Highlights
Julie Crawford, MD
Brenda Shinar, MD
Jayne Peterson, MD
Cheryl W. O’Malley, MD
Clinical Pearls
Update in Hospital Medicine
Julie Crawford, MD
Hospitalist
Phoenix VA Healthcare System
May 2013
22
Clinical Pearl #1
Mrs. P is an 82yo female with a PMH sig for HF (EF 35%), HTN, DM, h/o
remote CVA and atrial fibrillation (on AC) who is admitted for
management of a left femoral neck fracture that occurred when the
patient tripped on a rug in her house and fell.
• INR was 2.2 on admission.
• She was given FFP just prior to undergoing an uncomplicated Left
Total Hip Arthoplasty.
• Postoperative INR = 1.6
• CHADS2 score is 6.
When should you start heparin bridging in this patient?
• A: Immediately after surgery
• B: 12 hours after surgery
• C: 48 hours after surgery
• D: At least one week after surgery
3
Clinical Pearl #1
ANSWER: C. 48 hours after surgery
4
Clinical Pearl #1
Why? C. 48 hours after surgery
• Current clinical guidelines for peri-procedural anticoagulation
management
 Based on expert opinion
 Place a relatively high value on preventing VTE and a
relatively lower value on preventing bleeding
 Based on limited data regarding the risks of bleeding
5
Clinical Pearl #1
Evidence
Predictors of major bleeding in peri-procedural
anticoagulation management.
Tafur A.J., McBane R, Wysokinski E, Litin S, Daniels P, Slusser J, Hodge D, Beckman MG, Heit JA
Journal of Thrombosis and Haemostasis. 2012: 10:261-267
• OBJECTIVE: “to determine the 3 month cumulative incidence and
independent predictors of peri-procedural bleeding in chronically
anticoagulated patients requiring temporary warfarin interruption for
an invasive procedure”
6
Clinical Pearl #1
Study Details
• Protocol Driven, Cohort study
• Mayo Clinic
• 1997-2007
• N=2182
• Used protocols to determine management of
perioperative anticoagulation
• Patients were followed forward for 3 months
Predictors of major bleeding in peri-procedural anticoagulation management.
Tafur A.J., McBane R, Wysokinski E, Litin S, Daniels P, Slusser J, Hodge D, Beckman MG, Heit JA
Journal of Thrombosis and Haemostasis. 2012: 10:261-267
7
Clinical Pearl #1
Findings
• Overall bleeding 5.1%, Major bleeding 2.1%
• Major bleeding was more frequent in patients receiving
heparin bridging (3% vs. 1%); There was no difference in
thrombosis rates.
• INDEPENDENT PREDICTORS OF MAJOR BLEEDING:
 Mitral mechanical valves
 Active Cancer
 Prior bleeding history
 Restarting heparin within 24 hours of surgery
– ALL of the major bleeding events occurred in patients who resumed full
dose heparin within 24 hours of the procedure
– NO events in full dose heparin starting >48 hours following the
procedure.
Predictors of major bleeding in peri-procedural anticoagulation management.
Tafur A.J., McBane R, Wysokinski E, Litin S, Daniels P, Slusser J, Hodge D, Beckman MG, Heit JA
Journal of Thrombosis and Haemostasis. 2012: 10:261-267
8
Clinical Pearl #1
Recommendations
• Authors’ practice has changed to err on the side of
reducing bleeding risk
 Wait 48h post-procedure prior to initiating therapeutic heparin
 Therapeutic heparin bridging recommended only in those who
are at high risk of TE
– h/o VTE in past 3 mo
– Afib w/ prior CVA, TE, or intracardiac thrombus
– Prosthetic heart valves (other than aortic bileavlet valves)
– Mechanical heart valves with a h/o coexistent afib, prior CVA,
TE, or known intracardiac thrombus
Predictors of major bleeding in peri-procedural anticoagulation management.
Tafur A.J., McBane R, Wysokinski E, Litin S, Daniels P, Slusser J, Hodge D, Beckman MG, Heit JA
Journal of Thrombosis and Haemostasis. 2012: 10:261-267
9
CLINICAL PEARL #1
• Initiation of bridging heparin within 24 hours
of surgery is associated with major bleeding.
Better guidelines are needed to determine the
optimal timing of postoperative heparin
bridging.
10
Johns Hopkins Consultative Medicine Essential for Hospitalists
www.jhcape.com
Module on Perioperative Management of Anticoagulation
11
Clinical Pearl #2
After surgery, Mrs. P is feeling well. She
denies any symptoms of chest pain or
shortness of breath.
Should you check a troponin level to assess her for
possible postoperative acute MI?
• A: Yes
• B: No
• C: Maybe
12
Clinical Pearl #2
ANSWER: C. Maybe
13
Clinical Pearl #2
Why? C. Maybe
• Hip fracture surgery is the most common noncardiac surgical procedure in the elderly
• Current Perioperative guidelines suggest that
risk of cardiac complications from orthopedic
procedures is 1-5%
 NOT specific for hip fracture
14
Clinical Pearl #2
Evidence
Clinical Presentation and Outcome of Perioperative
Myocardial Infarction in the Very Elderly Following
Hip Fracture Surgery.
Gupta B, Huddleston J, Kirkland, L, Huddleston P, Larson D, Gullerud R, Burton MC, Rihal C, Wright RS.
Journal of Hospital Medicine Nov/Dec 2012 7(9); pg 713-716
• OBJECTIVE: “To define the clinical presentation of PMI and its
outcomes among elderly patients admitted for hip fracture surgery”
15
Clinical Pearl #2
Study Details
• Population-based, retrospective, case control study
• 1988-2002; Residents of Olmsted County, Minnesota;
age >65 (average age 85.3yrs)
Clinical Presentation and Outcome of Perioperative Myocardial Infarction in the Very
Elderly Following Hip Fracture Surgery.
Gupta B, Huddleston J, Kirkland, L, Huddleston P, Larson D, Gullerud R, Burton MC, Rihal C, Wright RS.
Journal of Hospital Medicine Nov/Dec 2012 7(9); pg 713-716
16
Clinical Pearl #2
Findings
In 1212 patients with hip fracture surgeries
13.8% of cases suffered PMI in the first 7 days after
surgery
– 92% PMI occurred within the first 48 hours
– 75% of patients were ASYMPTOMATIC
– 22.8% had ECG changes consistent with ischemia
PMI was associated with higher mortality
– In hospital deaths (14.4% of PMI group vs. 1.2% of non-PMI group
– 30 d mortality (17.4% PMI vs. 4.2% non-PMI)
– 1y mortality (29% PMI vs. 23% non PMI)
Most of the PMI patients in this study were identified
w/ cardiac biomarkers
Clinical Presentation and Outcome of Perioperative Myocardial Infarction in the Very
Elderly Following Hip Fracture Surgery.
Gupta B, Huddleston J, Kirkland, L, Huddleston P, Larson D, Gullerud R, Burton MC, Rihal C, Wright RS.
Journal of Hospital Medicine Nov/Dec 2012 7(9); pg 713-716
17
Clinical Pearl #2
Findings Cont.
• CONCLUSIONS:
“Elderly patients have a higher incidence of PMI and mortality
after hip fracture than what current guidelines indicate”
 “Results support the measurement of troponin in
postoperative elderly patients for diagnosis of PMI to
implement in-hospital preventive strategies to reduce PMIassociated mortality “
Clinical Presentation and Outcome of Perioperative Myocardial Infarction in the Very
Elderly Following Hip Fracture Surgery.
Gupta B, Huddleston J, Kirkland, L, Huddleston P, Larson D, Gullerud R, Burton MC, Rihal C, Wright RS.
Journal of Hospital Medicine Nov/Dec 2012 7(9); pg 713-716
18
Clinical Pearl #2
Does postoperative troponin level predict
mortality?
19
Clinical Pearl #2
Evidence
Association Between Postoperative Troponin Levels
and 30-day Mortality Among Patients Undergoing
Noncardiac Surgery
JAMA 2012; 307(21): 2295-2304
• OBJECTIVE: “To determine the relationship between the peak fourthgeneration troponin T (TnT) measurement in the first 3 days after
noncardiac surgery and 30-day mortality”
20
Clinical Pearl #2
Study Details
• VISION study: a prospective cohort study designed to
evaluate major complications after noncardiac
surgery
• N. and S. America, Africa, Asia, Australia, and Europe
• 15,133 patients; age >=45yo
• 2007-2011
• Measured Troponin T level 6-12 hours after surgery
and on postop days 1, 2, and 3
Association Between Postoperative Troponin Levels and
30-day Mortality Among Patients Undergoing Noncardiac Surgery
JAMA 2012; 307(21): 2295-2304
21
Clinical Pearl #2
Findings
• 30 day mortality rate was 1.9% (282 deaths)
• Peak TnT values >=0.02ng/mL were independently
associated with a higher 30-day mortality compared
with the reference group
*note; most labs consider <0.04ng/mL to be WNL
• The higher the peak TnT value, the shorter the median
time to death
• 74.2% of patients with elevated TnT had elevation
within 24 hours of surgery
Association Between Postoperative Troponin Levels and
30-day Mortality Among Patients Undergoing Noncardiac Surgery
JAMA 2012; 307(21): 2295-2304
22
Clinical Pearl #2
Association Between Postoperative Troponin Levels and
30-day Mortality Among Patients Undergoing Noncardiac Surgery
JAMA 2012; 307(21): 2295-2304
23
Clinical Pearl #2
Conclusions
• The peak fourth-generation TnT measurement in the first 3 days after
noncardiac surgery is strongly associated with 30 day mortality.
• Monitoring Troponin levels for first 3 days after surgery improves the 30d
mortality RISK STRATIFICATION compared with assessing patients based on
preoperative risk factors alone
• “Clinical trials are needed to establish whether intervention taken in patients
with elevated troponin subsequent to noncardiac surgery would result in lower
risk of death.”
Association Between Postoperative Troponin Levels and
30-day Mortality Among Patients Undergoing Noncardiac Surgery
JAMA 2012; 307(21): 2295-2304
24
CLINICAL PEARL #2
• Elderly patients undergoing hip repair have a
higher rate of post-op AMI than previously
thought; and they are often asymptomatic.
Troponin levels predict mortality after
noncardiac surgery but more clinical trials are
needed to determine if routine monitoring is
indicated.
25
Clinical Pearl #3
Mr. D is a 78 yo male with PMH sig for HTN, DM, HF and
Afib (anticoagulated with warfarin) who was admitted for
management of hematemesis and abdominal pain.
• Tachycardic and hypotensive
• Emergent EGD revealed a bleeding peptic ulcer.
• Hemostasis was successfully achieved during the EGD.
When would you restart warfarin in this patient?
•
•
•
•
A: Immediately
B: Within one week
C: In one month
D: Never
26
Clinical Pearl #3
ANSWER: B. Within one week
27
Clinical Pearl #3
Why? B. Within one week
• Currently, there is a lack of high quality
evidence to help answer this question
28
Clinical Pearl #3
Evidence
Risk of Thromboembolism, Recurrent Hemorrhage,
and Death After Warfarin Therapy Interruption for
Gastrointestinal Tract Bleeding
Witt D, Delate T, Garcia D, Clark N, Hylek E, Ageno W, Dentali F, Crowther M.
Archives of Internal Medicine 2012; 172(19):1484-1491
OBJECTIVE:
• to determine the incidence of subsequent thrombosis, recurrent
GIB, and death in warfarin-treated patients who experienced GIB
• to determine the time to resumption of warfarin therapy
29
Clinical Pearl #3
Study Details
• Retrospective, Cohort study using databases
from Kaiser Permanente Colorado
• 442 patients with warfarin-associated GIB
were followed for 90days
 260 patients (58.8%) resumed warfarin therapy
Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy
Interruption for Gastrointestinal Tract Bleeding
Witt D, Delate T, Garcia D, Clark N, Hylek E, Ageno W, Dentali F, Crowther M.
Archives of Internal Medicine 2012; 172(19):1484-1491
30
Clinical Pearl #3
Findings
• Multivariate analysis performed on findings to account for
confounding factors
 THROMBOSIS: Warfarin therapy resumption was
associated with a lower risk for thrombosis (0.4% vs. 5.5%)
– No thrombosis seen in patients who resumed warfarin within 14
days of the GIB
 RECURRENT GIB:
– 8.4% (36) had a recurrent GIB
 10% of those who resumed warfarin
 5.5% of those who did not resume warfarin
 This difference was not statistically significant (lacks power due
to low number)
– No recurrent GIB resulted in death
Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy
Interruption for Gastrointestinal Tract Bleeding
Witt D, Delate T, Garcia D, Clark N, Hylek E, Ageno W, Dentali F, Crowther M.
Archives of Internal Medicine 2012; 172(19):1484-1491
31
Clinical Pearl #3
Findings Cont.
• Multivariate analysis performed on findings to account for
confounding factors
 DEATH: 11.8% (52) of patients died within 90d
– NO deaths were attributable to recurrent GIB
– Most common causes of death:
 Malignancy
 Infection
 Cardiac disease
– Warfarin therapy resumption was associated with a lower risk for
death
 Median time to resumption of warfarin was 4 days
following index GIB (2-9d)
Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy
Interruption for Gastrointestinal Tract Bleeding
Witt D, Delate T, Garcia D, Clark N, Hylek E, Ageno W, Dentali F, Crowther M.
Archives of Internal Medicine 2012; 172(19):1484-1491
32
Clinical Pearl #3
Conclusions
• “The decision NOT to resume warfarin therapy within the
90d following a GIB is associated with increased risk for
thrombosis and death.”
• “Resumption of warfarin therapy between 1-7days
following a GIB was associated with a higher risk if
recurrent GIB but lower risk of thrombosis.”
 “Clinical judgment remains a critical factor in deciding
exactly when to restart warfarin”
 Further research is needed to determine the optimal
duration of interruption after a GIB event
Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy
Interruption for Gastrointestinal Tract Bleeding
Witt D, Delate T, Garcia D, Clark N, Hylek E, Ageno W, Dentali F, Crowther M.
Archives of Internal Medicine 2012; 172(19):1484-1491
33
Clinical Pearl #3
Commentary
Resuming Anticoagulation in the First Week
Following Gatrointestinal Tract Hemorrhage.
Brotman D, Jaffer A.
Arch Intern Med 2012; 172 (19) 1492-1493
“most patients with warfarin-associated GI bleeding and
indications for continued long-term antithrombotic therapy
should resume anticoagulation within the first week following
the hemorrhage, approximately 4 days afterward.”
34
CLINICAL PEARL #3
• Not resuming warfarin within 90 days of GI
bleed is associated with increased thrombosis
and death.
• Restarting warfarin is not associated with
significantly increased bleeding.
• Further research is needed to identify the
optimal duration of warfarin interruption but
many suggest resuming anticoagulation within
the first week after a GI bleed, usually about 4
days after the bleed.
35
Summary
• CLINICAL PEARL #1
 Initiation of bridging heparin within 24 hours of surgery is associated with
major bleeding. Better guidelines are needed to determine the optimal timing
of postoperative heparin bridging.
• CLINICAL PEARL #2
 Elderly patients undergoing hip repair have a higher rate of post-op AMI than
previously thought; and they are often asymptomatic. Troponin levels predict
mortality after noncardiac surgery but more clinical trials are needed to
determine if routine monitoring is indicated.
• CLINICAL PEARL #3
 Not resuming warfarin within 90 days of GI bleed is associated with increased
thrombosis and death.
 Restarting warfarin is not associated with significantly increased bleeding.
 Further research is needed to identify the optimal duration of warfarin
interruption but many suggest resuming anticoagulation within the first week
after a GI bleed, usually about 4 days after the bleed.
36
Things I learned at ACP 2013
Brenda Shinar, MD
Case
•
ID and CC:
A 52 year-old Hispanic man
with history of NASH
cirrhosis presents to the ED
with 2 days of melena and
one episode of coffeeground emesis
• PMH:
– Type 2 diabetes
– HTN
– Cirrhosis due to NASH
with small varices 2/2013
• Exam:
VS: 109/67 HR 78 RR 18
T 98.6 F 99% RA
Rectal: black stool guaiac +
• Labs:
Hgb 7.7 g/dL (2/2013 7.3)
MCV 77
RDW 18.1
Platelets 72,000
INR 1.2
Three Questions
1. What are the risks of blood
transfusion in 2013?
2. At what hemoglobin should I
consider transfusion in a
hemodynamically stable patient with
anemia?
3. Is the laboratory evaluation of
nutritional deficiencies contributing
to anemia accurate after blood
transfusion?
Risk of Transfusion
• Extremely low risk of infections that we know about,
but still inherently dangerous and risk of unknown
pathogens
• Patients can die from transfusions:
– TRALI is most common cause
– Hemolytic transfusion reaction: second
– Transfusion associated circulatory overload : third
• Two reasons for malpractice regarding transfusions:
– Did not ask for patient permission
– Gave unnecessarily
Diabetes:
Expanding my view and trying something new
Patient Centered Care:
Putting it into practice
Lessons Learned From: Anne L. Peters, MD, FACP
PATIENT PRESENTATION
46 year old woman with Hypertension, Hyperlipidemia & Diabetes diagnosed
8 years ago presents for follow up.
Current Medications: Metformin 1000mg bid
Lisinopril 5mg daily,
Simvastatin 10mg each evening
HPI: She checks her blood sugar 3 times per week and the last several
months noticed that her fasting blood sugars are running high – 240. She
has tried to modify her diet more – smaller portions. ROS unremarkable
except occasional polydipsia, no hypoglycemia
PE: 130/82 72 weight : 220lbs with BMI 30.7
What is the treatment goal ?
What other information do you need to know?
BACK TO OUR PATIENT
• HbA1c 3 months ago was 7.5 and now is 8.8
• Normal Cr and LFT’s
• Weight up 8 pounds from 3 months ago
Do you have enough information to adjust medication management?
PATIENT-CENTERED APPROACH
“Providing care that is respectful of and responsive to individual
patient preferences, needs and values. Ensuring that patient’s
values guide all clinical decisions. “
• Gauge patient’s preferred level of involvement
• Shared decision making: final decision making regarding
lifestyle choices ultimately lies with the patient
• Explore therapeutic choices with patient when available
MY LESSONS LEARNED
•
Utilize all medication options – good evidence to support GLP-1 Agonists as 2nd
line therapy in selected patients: Need to overcome my personal barriers –
expectations of patient resistance to injections, insurance authorization,
inexperience with the medication
•
When instituting insulin therapy – ok to start with just one meal time coverage to
help patient adjust to the therapy.
•
Involve patient early on in the shared decision making by learning about their
lifestyle and values.
“Know your person before attempting to do them good”
- Nathanial Hawthorn
A FEW OF MY FAVORITE
THINGS…


A 35 year old woman with a BMI of 31 has a 3 year
history of RUQ pain. The pain is characterized as 3/10
dull ache in the RUQ and is present most of the time
but is aggravated by eating. It has not progressed. It is
associated with occasional nausea but no vomiting.
She has a tendency toward constipation. She is tender
in the RUQ. Her AST, ALT, and alkaline phosphatase
are normal. RUQ ultrasound is normal with no stones
and a HIDA scan shows an ejection fraction of 18%
(normal > 35%). During the HIDA she develops
abdominal discomfort similar to her pain.
You recommend:
A. Proton pump inhibitor (PPI)
B. Cholecystectomy
C. Colonoscopy
D. Abdominal CT
E. Symptomatic treatment with dicyclomine
Biliary Dyskinesia
EPISODIC RUQ pain/epigastrium >30
min
 Severe enough to interrupt normal daily
activities
 Low EF with CCK stimulation

CLINICAL PEARL:
Decisions for cholecystectomy should not be based on HIDA
alone. A clinical history is the best discriminator of biliary
dyskinesia and can be confirmed by a HIDA scan.
References:
1. Hansel SL and DiBaise JK. Functional Gallbladder Disorder: Gallbladder Dyskinesia. Gastroenterol Clin N
Am 2010;39: 369-379
2. Francis G and Baillie J. Gallbladder dyskinesia: Fact or Fiction? Curr Gastroenterol Rep 2011; 13:188-192.
From: Clinical Pearls Gastroenterology- John A. Schaffner, MD


A 58 year old woman has right sided upper abdominal
pain for the last 2 years. The pain is present 24/7 at a
level that fluctuates between 3-7/10. She cannot
pinpoint a cause when it started and it has not changed
over the 2 years. It is aggravated by eating on
occasion, by constipation, and by sitting for long
periods. A CT scan, RUQ ultrasound, EGD, and
colonoscopy are normal. On exam she can point to the
location of a tender area with one finger in the MCL in
the RUQ.
Which of the following would you recommend?
A. Repeat EGD
B. Surgical consultation
C. Trigger point injection
D. MRI of the abdomen
E. Hydrocodone
CLINICAL PEARL:
Increased tenderness at the symptomatic spot when the
abdominal muscles are tensed either by raising the head or legs
(A positive Carnett’s sign) can be confirmatory for abdominal wall
pain. Abdominal wall pain is often overlooked and the diagnosis is
made by history and physical exam.
References:
1. Lindsetmo RO, and Stulberg J. Chronic abdominal wall pain-a diagnostic challenge for the surgeon. Am J
Surg 2009; 198:129-134.
2. Peery AF, Dellon ES, Lund J, et al. Burden of Gastrointestinal Disease in the United States: 2012 Update.
Gastroenterology 2012; 143:1179-1187
.
From: Clinical Pearls Gastroenterology- John A. Schaffner, MD

A 54 year old man has long standing heartburn that is
well controlled by taking a PPI once a day. He is
currently asymptomatic. You recommend an EGD, his
first, which demonstrates 3 cm. of Barrett’s esophagus
with no dysplasia on biopsy.

Which of the following would be the next step?
A. Repeat endoscopy in 3 years
B. Endoscopic ablation of Barrett’s epithelium
C. Increase his PPI dose
D. Fundoplication
E. No further surveillance
Endoscopy in GERD




1) in anyone with alarm symptoms that include
dysphagia, bleeding, anemia, weight loss, and
recurrent vomiting;
2) in patients with typical symptoms who do not
improve on twice daily PPI therapy;
3) in patients with severe or stricturing disease;
4) in men over the age of 50 with a more than 5 year
history of GERD and other risk factors that include
nocturnal reflux, hiatal hernia, elevated BMI and
smoking.
Shaheen NJ, Weinberg DS, Denberg TD, et al. Upper endoscopy for gastroesophageal
reflux disese: best practice advice from the clinical guidelines committee of the American
College of Physicians. Ann Intern Med 2012; 157:808-816.
CLINICAL PEARL:
In the absence of dysplasia in intestinal metaplasia, a surveillance
interval of 3 years is recommended. There is growing controversy
about treatment of Barrett’s esophagus.
References:
1. Wani S, Falk G, Hall M, et al. Patients With Nondysplastic Barrett's Esophagus Have Low Risks for
Developing Dysplasia or Esophageal Adenocarcinoma; Clinical Gastroenterology and Hepatology 2011 9:
220-227.
2. American Gastroenterological Association Medical Position Statement on the Management of Barrett’s
Esophagus. Gastroenterology 2011;140:1084 –1091
.
From: Clinical Pearls Gastroenterology- John A. Schaffner, MD

A 28-year-old female is concerned about a worsening
facial rash, thought to be dermatitis. She originally
placed over-the-counter hydrocortisone on the rash
twice a day without improvement. She then borrowed
her daughter’s triamcinolone prescription for twice daily
use. The rash continues to progress. The patient is
otherwise healthy and has normal menstrual cycles.

What is the best treatment for this condition?
A. Institute topical clobetasol BID
B. Discontinue cosmetics and patch test for allergic contact
dermatitis
C. Discontinue topical steroids and institute judicious sunscreen use
D. Discontinue topical steroids and institute topical metronidazole
BID
E. Discontinue topical steroids and institute topical tretinoin QHS
Clinical Pearl:
Topical steroids worsen perioral dermatitis. Topical
metronidazole is the preferred treatment.
http://www.dermnetnz.org/acne/img/perioraldermatitis/source/11.html
Multiple Small Feedings of the Mind
For patients with atrial fibrillation, what
are the best evidence-based risk
stratification models to estimate
bleeding risk?

69 year female with paroxysmal atrial fibrillation.
History of controlled HTN and MI on metoprolol, normal
LV function• No diabetes, no prior TIA or CVA. Normal
kidney and liver function. No history of bleeding, no
EtOH. Mild-moderate SOB when she goes intoAfib,
HR about 115bpm

What is the best treatment for this condition?

http://www.sparctool.com/
Complex Issues in anticoagulation:
Tracy A. Minichiello, MD- UCSF

Minimum effective duration oftherapy for VTE is 3
months.
 If event is unprovoked consider indefinite
anticoagulation if bleeding risk is low
 Assess individual risk benefit of extended therapy
using d-dimer and clinical risk scores
 In general, avoid expense of comprehensive testing
for laboratory thrombophilia given limited role in
determining duration of anticoagulation in VTE
 Consider ASA for secondary prevention of recurrent
VTE in patients with unprovoked events who are not
candidates for ongoing anticoagulation
Summary Clinical Pearls






Decisions for cholecystectomy should not be based on HIDA
alone. A clinical history is the best discriminator of biliary
dyskinesia.
Abdominal wall pain is often overlooked and the diagnosis is
made by history and physical exam. –Carnett’s sign
In the absence of dysplasia in intestinal metaplasia (Barrett’s), a
surveillance interval of 3 years is recommended.
Topical steroids worsen perioral dermatitis. Topical
metronidazole is the preferred treatment.
Use the decision calculators to help with anticoagulation
decisions in a fib http://www.sparctool.com/
For DVT/PE- individualize the duration of rx based on what the
event was, follow up d dimer and consider ASA as a potential
continued rx if don’t continue full anticoagulation.
But wait there is more!”Recruit a Resident Rewards”
http://www.acponline.org/private/membership/rar12/
Questions?