Última Sessão da Clínica Médica de 2013

Última sessão da Clínica Médica de 2013

Turma Dezembro - 2013

Novos guidelines de hipertensão arterial sistêmica em adultos (JNC 8) mais lenientes com o controle pressórico

Caros,

Foi publicado no JAMA, em 18 de dezembro, o JNC 8 (2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults - 8th Joint National Committee) com guidelines sobre hipertensão arterial sistêmica em adultos.

Mais conciso e simples em número de páginas (14) e recomendações, aparentemente no estilo "menos é mais", essas atualizações se somam aos novos guidelines de obesidade e ao polêmico guideline de dislipidemia também publicados nesse ano. Lembrem que o último JNC 7 era de 2003!

As principais mudanças foram na leniência no controle pressórico, escolha de medicações e alternativas para hipertensão resistente.

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Veja o algoritmo abaixo junto com comentários do MEDSCAPE.

Comentários do Medscape

http://www.medscape.com/viewarticle/817991

CHICAGO, IL — At long last, the Eighth Joint National Committee (JNC 8) has released its new guidelines on the management of adult hypertension, which contain two key departures from JNC 7 that the authors say will simplify care[1].

For one, the expert writing group recommends a relaxing of the more aggressive JNC 7 target blood pressures and treatment-initiation thresholds in elderly patients and in patients under age 60 with diabetes and kidney disease. JNC 8 also backs away from the recommendation that thiazide-type diuretics should be initial therapy in most patients, suggesting an ACE inhibitor, angiotensin-receptor blocker (ARB), calcium-channel blocker (CCB), or thiazide-type diuretic are reasonable choices.

 We wanted to make the message very simple for physicians.

"Our goal was to create a very simple document," lead author on the new guidelines, Dr Paul A James (University of Iowa, Iowa City), told heartwire . "We wanted to make the message very simple for physicians: treat to 150/90 mm Hg in patients over age 60 and 140/90 for everybody else. And we simplified the drug regimen as well, to say that any of these [four] choices are good, just get people to goal. Monitor them, track them, remonitor them. That's a very simple message."

The 14-page, JNC 8 guidelines include a detailed treatment algorithm and a handy table spelling out key differences between JNC 7 and JNC 8. The authors also published over 300 pages in an online supplement outlining their evidence review process, including reviewer commentary. The guidelines themselves were constructed around three questions, which James notes were developed at the outset of the evidence review: Does initiating therapy at specific BP thresholds improve health outcomes? Does drug treatment to specified goals improve health outcomes? And do different drugs/drug classes differ in benefits and harms?

Nine Recommendations

Those questions then form the basis for nine recommendations, discussed in depth and assigned a score for both the strength of the recommendation and the evidence supporting it. Among the recommendations:

• In patients 60 years or over, start treatment in blood pressures >150 mm Hg systolic or >90 mm Hg diastolic and treat to under those thresholds.
• In patients <60 years, treatment initiation and goals should be 140/90 mm Hg, the same threshold used in patients >18 years with either chronic kidney disease (CKD) or diabetes.
• In nonblack patients with hypertension, initial treatment can be a thiazide-type diuretic, CCB, ACE inhibitor, or ARB, while in the general black population, initial therapy should be a thiazide-type diuretic or CCB.
• In patients >18 years with CKD, initial or add-on therapy should be an ACE inhibitor or ARB, regardless of race or diabetes status.

A key point, said James, is that while the targets have been loosened, the new guidelines do not mean that physicians should ease up on treatment in a patient who is doing very well based on JNC 7 guidance.

"We wanted to be crystal clear about where the evidence is to support these recommendations. We are not saying that if you've gotten someone's [systolic] BP to 140 or 135 mm Hg on medicine and they are doing well that you need to take them off medicines and get their BP closer to 150. We are simply saying, if you can consistently get people's BP below 150, you really are improving their health outcomes."

He acknowledged that critics will worry that raising the threshold to 150 mm Hg in older subjects will mean real-world blood pressures far greater. James called this the "speed-limit rule," suggesting that no matter what the target is, people will hover above it, rather than being more likely to get patients to goal.

"I do think there's always a concern about people not following the recommended targets; however, we have to start somewhere, and our panel's opinion is that we should start where the evidence leads us," James said. "In one sense, you're fooling people by saying, 'Let's pretend it's 140 mm Hg so we have a little leeway,' and that doesn't feel exactly right."

The Long Wait for JNC 8

Physicians have waited so long for "JNC-Late" it's possible they've forgotten what they were looking for in the first place. Not a bad thing, since the "2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults" is a very different document from JNC 7, published in 2003. While the National Heart, Lung, and Blood Institute (NHLBI) originally commissioned the JNC 8 guidelines and appointed the commission members in 2008, the federal agency announced earlier this year that it was handing off the task of guideline writing to the American College of Cardiology and the American Heart Association (ACC/AHA).

As reported by heartwire , those organizations released four of the formerly NHLBI-sponsored guideline documents last month, swiftly followed by a "scientific advisory" offering "an effective approach to high blood-pressure control," presumably to fill the yawning gap represented by the missing JNC 8 guidelines.

To heartwire , James said that JNC 8 members decided, after the NHLBI announcement, that they were not interested in having ACC/AHA put their imprimatur on the guidelines and opted to press ahead on their own, although all of their interactions with the cardiology organizations were cordial. "They are wonderful organizations, and I have nothing but the utmost respect for the individuals I interacted with," he insisted.

We haven't shopped this guideline around to seek that kind of approval.

Instead, the commission submitted JNC 8 guidelines to the Journal of the American Medical Association and in the paper states: "This report is . . . not an NHBLI-sanctioned report and does not reflect the views of NHLBI."

Asked about the ACC/AHA scientific advisory on hypertension, James said he sees "no relationship between the two documents" and played no part in the other document's development.

"Our intention was to get our guideline out into the public arena, to get peer review, and we purposely have not sought to be endorsed by any professional group or society, any insurance company, or any federal agency. We haven't shopped this guideline around to seek that kind of approval. Our hope is that this guideline will be read and digested and that the societies look at this work and say yes, this is valid work, and we need to follow these guidelines, or no, it's not."

Of note, JNC 8 is mostly in line with the European Society of Hypertension (ESH) guidelines released earlier this year, which suggested a target of <140 mm Hg systolic BP for "all" patients, with some caveats. In patients with diabetes, the ESH guidelines suggest a diastolic BP of <85 mm Hg, and for patients under 80 years, they suggest a target of between 140 and 150, going lower only if the patient is fit and in good health. And joining in on guideline-palooza, the American Society of Hypertension and International Society of Hypertension announced late yesterday that they, too, are releasing new guidance, targeting management of hypertension in the community.

A Chorus of Opinions

JNC 8 is accompanied by three editorials. One, by Dr Harold C Sox (Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH), addresses the "trustworthiness" of the new hypertension guidelines[2]. Sox points out that the JNC 8 guidance adheres much more closely to quality standards published by the Institutes of Medicine (IOM) in 2011 (Clinical Practice Guidelines We Can Trust) than it does the JNC 7 document: a strength, implies Sox. Most notably, the JNC 8 members published their methods online along with detailed comments from reviewers. In a separate editorial, JAMA editor in chief Dr Howard Bauchner (Boston University School of Medicine, MA) and colleagues note that the guideline documents released by the ACC/AHA "have been met with controversy"—a key complaint being the lack of a transparent peer-review process[3].

Finally, Dr Eric Peterson (Duke University, Durham, NC) and colleagues (all associate or senior editors at JAMA) tackle the "goals and purposes" of hypertension recommendations[4].

Speaking with heartwire , Peterson pointed to the fact that the loosening of targets is as much based on a lack of evidence as it is on new evidence.

"Don't you find it fascinating that high cholesterol and high blood pressure are two of our most prominent risk factors for cardiovascular disease, we've known effective therapies for those two things for 10, 20, and in some cases 30 years, yet we still don't know what the right treatment targets should be, or indeed, whether we should have targets at all?"

As such, he notes, it's striking that the approach taken by the JNC 8 document contrasts sharply with that taken in the new ACC/AHA guidelines on cholesterol. While the latter abandoned treatment goals and recommended a more aggressive approach in elderly patients, JNC 8 has done the opposite: specified treatment targets and advocated a less aggressive approach in the elderly.

"I think this will instill some debate: did they get the thresholds right?" Peterson commented. He hopes it will also spur calls for more research to answer the many questions not addressed in the document.

A final issue, and one also raised by James in his interview with heartwire , is what the new JNC 8 recommendations will mean for performance measures, which have been taken up by insurers and payers to determine benchmarks of care.

"One of the things the panel certainly had to wrestle with was, after JNC 7, one of the unintended consequences was that insurance companies and those who measure quality said every patient needs to have a BP under 140/90," James explained. "So what you have is doctors who want to achieve these BP measures having patients with 126/60 blood pressures, and when you are talking about elderly patients, who are already taking many other medications, taking additional drugs, and having their blood pressures pushed down that low, you have to really question whether you are doing good."

James had no conflicts of interest; disclosures for other members of JNC 8 are listed in the paper. Bauchner and Peterson had no conflicts, nor did their coeditorialists. Sox disclosed serving on IOM committees and having been a member of the Report Review Committee of the National Academies.

Caso Clínico para discussão na sessão do New England de 26/12/13 (ATUALIZADO)

Caros,

Segue caso clínico para discussão no New England de 26/12/13 (atualizado)

• Mulher de 53 anos com eritroderma, prurido e linfadenopatia

O caso completo será disponibilizado após a discussão.

• Case 24-2013: A 53-Year-Old Woman with Erythroderma, Pruritus, and Lymphadenopathy. N Engl J Med 2013;369:559-69.

Dica de App #16: Online2PDF - De Office para PDF, vice-versa e muito mais!

Caros,

A dica de hoje vai para para um aplicativo online que pode quebrar um grande galho.

Link: http://online2pdf.com

Você alguma vez já precisou:

• Converter um PDF para arquivo DOC, XLS, PPT ou OpenOffice?
• Converter um arquivo DOC, XLS, PPT ou OpenOffice para PDF?
• Mesclar vários arquivos PDF, DOC, XLS, PPT ou OpenOffice em um único PDF?
• Retirar PASSWORD, proibição de impressão, rodar páginas ou alterar a ordem de páginas de um arquivo PDF?

Então esse aplicativo pode te ajudar.

Podem ser processados até 20 arquivos por vez, desde que não se ultrapasse 50MB.
Mais informação sobre o que pode ser feito: http://online2pdf.com/features#pagecomposition

Confira! Fica a dica.

Quando fazer o gelo ("ICE") é muito bom para sua relação com seu paciente

"Pacientes terão ideias e sentimentos sobre o que acontece com eles, e esses podem ou não ser acurados"

Uma boa relação médico-paciente é fundamental. Uma forma possível de fortalecê-la, é que após uma escuta ativa, elaboração de hipóteses e estabelecimento do que julgamos ser prioridade, se aborde a percepção do paciente, a agenda da saúde dele, ou seu modelo de doença.

Para isso, podemos fazer o ICE:

I: Ideas (Ideias do paciente sobre o que está acontecendo com ele)

C: Concerns (Preocupações em termo de impacto na vida - podemos traduzir como Cismas :))

E: Expectations (Expectativas sobre a doença e sobre você, o médico)

"Pacientes terão ideias e sentimentos sobre o que acontece com eles, e esses podem ou não ser acurados. Um paciente com dor torácica pode pensar em indigestão enquanto você está considerando angina. Pergunte "Você tem alguma ideia sobre o que pode estar acontecendo com você / o sr.?". Uma questão simples como: "O que você / o sr. estava esperando dessa consulta hoje?" podem ajudá-lo a evitar investigações e prescrições desnecessárias. A medicina moderna pode ser incapaz de "curar" um problema, e o importante é o que você fazer para ajudar seu paciente a se manter funcional."

Texto traduzido.

Macleod’s Clinical Examination 13th Ed 2013

Então, nunca ignore a queixa principal de um paciente. Pode não fazer sentido para você, mas faz todo sentido para ele. Ajude-o a construir um novo modelo de doença, com informação na linguagem dele. Não afronte desconstruindo seu modelo de forma descuidada e verticalizada, mas quando possível e necessário, com cuidado e no tempo dele. Muitas vezes para somar e multiplicar não é necessário subtrair. ;)

Abraços,

Dica de App #15: Instapaper - para ler depois (read it later)

Dica de App #15: Instapaper - para ler depois (read it later)

Caros,

A dica de app dessa semana vai para o Instapaper, que é um agregador de textos da web, como um clipper que você utiliza para compilar textos para "leitura depois" e offline.Você pode compilar em pastas, utilizar tags e revisar tudo na web também.

Links:

• Instapaper for iOS (iPhone/iPad)
• Instapaper for Android

Ele está grátis até o dia 19 de dezembro, então, corra!

O preço normal é de US$ 3,99,  mas mesmo perdendo a promoção é um app que vale a pena ter.

A maioria dos serviço utiliza ou o Instapaper ou o Pocket (que também vale a pena conhecer).

Veja a descrição do app:

Description
Instapaper is the simplest way to save and store articles for reading: offline, on-the-go, anytime, anywhere, perfectly formatted.

Instapaper for iPhone, iPad and iPod touch provides a mobile-optimized Text view that makes reading Internet content a clean and uncluttered experience.

Instapaper Core Features:

- Save most web pages as text only, stripping away the full-sized layout to optimize for the iPhone and iPad screens. 
- Store up to 500 articles on your iPhone or iPad, and store unlimited articles on the Instapaper website.
- Read offline, even on airplanes, subways, on elevators, or on Wi-Fi-only devices away from Internet connections.
- Send to Instapaper from 150 other iPhone and iPad apps. 

Additional Features:

- Adjustable fonts, text sizes, line spacing, and margins
- Dark mode and brightness control for night reading
- Automatic Dark and Sepia Mode switching for sunset times in your location
- Sort your list of unread items by popularity, date, article length, and shuffle
- Filter your list of unread items by reading time

- Folders for organization
- Dictionary and Wikipedia lookups 
- Tilt scrolling, page-flipping 
- Share via email, Tumblr, Twitter, Facebook, Pinboard, Evernote, or other supported apps
- Rotation lock
- Preview links in the built-in browser without leaving the app
- Search, via in-app purchase

Accolades:

- Featured by Apple many times in the App Store, including both the iPhone and iPad Hall of Fame
- Macworld Editor's Choice Award
- Featured in Wired, TIME, Daring Fireball, TechCrunch, PCMag, TUAW, The Next Web, and many other magazines, newspapers, and websites

Screenshots

iPhone iPad

Caso Clínico para New England de 19/12/2013

Caros,

Segue o caso clínico para o New England de 19/12/203

• Um homem de 30 anos com febre e linfadenopatia

O artigo completo será disponibilizado após a discussão.

• Case 38-2013: A 30-Year-Old Man with Fever and Lymphadenopathy. N Engl J Med 2013;369:2333-43

Abraços,

CME - Varfarina

Caros,

Seguem alguns artigos e a apresentação relacionada ao no "CME" de varfarina.

• Apresentação - R1 Ana Paula 
• Apresentação PPTX
• Artigo: Practical tips for warfarin dosing and monitoring. CCJM 2003 70(4); 361-371 
• Apresentação - Paulo (Interno)
• Apresentação PPTX
• Artigo: Practical issues with vitamin K antagonists: elevated INRs, low time-in-therapeutic range, and warfarin failure. J Thromb Thrombolysis (2011) 31:249–258 
• Extras
• Link para 9th ACCP Antithrombotic Therapy and Prevention of Thrombosis Guidelines - todos os PDF Free
• Cleveland Clinic Patient information Handout

Alguns complementos e reforços:

• Para TVP confirmada, o ideal é começar o enoxaparina ou fondaparinux conjuntamente com Marevam e mantê-los por pelo menos 5 dias e até se ter 2 INR na faixa terapêutica (9th ACCP);
• Interações medicamentosas são a principal causa de variação significativa de INR. Sempre pesquisá-las.
• Os principais que aumentam:
• Amiodarona (por longos períodos, por ter grande meia vida)
• Metronidazol
• Sulfametoxazol com trimetropim
• Fluconazol / Cetoconazol / Itraconazol
• Os principais que diminuem:
• Carbamazepina
• Barbitúricos (fenobarbital p.ex.)
• Propiltiuracil e Metimazol
• Fenitoína pode aumentar inicialmente e após diminuir (por deslocar da albumina)
• Descompensação de doenças podem interferir no efeito da varfarina
• ICC descompensada → congestão hepática → diminuição de metabolismo → INR ↑
• Hipotireoidismo → diminui metabolismo fatores vit. K → INR  diminui
• Hipertireoidismo → aumento metabolismo fatores vit. K → INR aumenta
• Para sangramento importante induzido por de varfarina, independentemente do INR:
• PFC 10 ml/kg (ataque) para correr em 1 hora (preferência por BIC). UpToDate recomenda doses de até 15-30 ml/kg a depender da capacidade do paciente de tolerar volume.
• Vitamina K ampola 10 mg/ml apresentação EV - diluir em 50 ml de SF0,9% e fazer em 20-30 min (mais rapidamente pode dar anafilaxia, então recomenda-se sempre infusão mais lenta que 1 mg/min). UpToDate recomenda que dose pode ser repetida de 12/12h a critério. Efeito inicia com 2 horas, mas é máximo próximo a 24 horas.
• Pode ser necessário 5 ml/kg de 6/6h (se dúvida da manutenção do sangramento) - cuidado com sobrecarga de volume.
• SEMPRE pesquisar a causa do sangramento
• Infelizmente, o complexo protrombínico e fator VIIa, no HEMOCE, só são reservados aos hemofílicos.
• Varfarina não pode ser utilizada quando há suspeita de trombocitopenia induzida por heparina até a normalização das plaquetas e se iniciada inadvertidamente, deve ser revertida com Vitamina K. 
• Varfarina deve ser iniciada com muito cuidado em pacientes com deficiência de Proteína C e S.

Abraços,

Caso clínico p/ discussão no New England de 12/12/2013

Caros,

Segue caso clínico para discussão no New England de 12/12/2013

• Homem de 49 anos admitido com febre, dor e paralisias de nervos cranianos após tratamento de carcinoma escamoso oral.

Após a discussão o artigo será disponibilizado.

Artigo:

• Case 29-2012: A 49-Year-Old Man with Pain and Cranial-Nerve Palsies after Treatment of Oral Cancer. N Engl J Med 2012;367:1136-47.

Abraços,

A Queda dos Antibióticos

Caros,

Como se dá a queda dos antibióticos (ATB)? 
Hitler explica...

Então, sempre que possível:

• Prescrever antibióticos com critérios clínicos específicos
• Orientar o paciente quando não houver necessidade de antibióticos (o paciente pode querer antibiótico pelo modelo de doença que tem na cabeça dele, mas ele não tem obrigação de saber as indicações. Cabe a nós aplacar essa expectativa com uma boa anamnese e exame físico e não simplesmente frustrá-la ignorando-a)
• Se guiar por culturas, sempre que possível
• Deescalonar antibiótico ao receber resultados positivos de cultura, se guiando pelo TSA.

Abraços,

Caso Clínico para o New England de 05/12/2013

Caros,

Segue caso clínico para discussão no New England de 05/12/2013

• Homem de 41 anos, HIV positivo, admitido com dor abdominal, torácica e mal estar
• Case 37-2013: A 41-Year-Old Woman with Malaise and Chest and Abdominal Pain. N Engl J Med 2013;369:2138-45.

Abraços,

Clínica médica NOVEMBRO de 2013

Despedida (ou até logo) da clínica médica em Novembro de 2013