Hot Topics in Hospital Medicine 2019: Endocarditis Treatment Dilemma
Hot Topics in Hospital
Medicine 2019
Noppon Setji
Hilton Head SC
Disclosures
•
None
•
Lack of proven
scientific method
Case 1
•
27 yo Male who is an active heroin user is admitted to the hospital
with endocarditis. Because the patient is still doing heroin, many of
the providers want the patient to remain in the hospital for 6 weeks
of therapy. The patient feels well and is independent in spirit and
does not want to stay in the hospital. What do you recommend?
•
A. Discharge the patient with a PICC line home to complete 6 weeks
of therapy
•
B. Pick some oral antibiotic regimen that should work and send him
out
•
C. Make the patient stay in house for 6 weeks for IV therapy
•
D. It Depends
Background
POET
•
Trial Design
•
Objectives: To evaluate whether patients with left
sided infective endocarditis could be switched to an
oral antibiotic regimen that would result in similar
outcomes
•
Design:Multi-center; randomized, Non-inferiority Trial
•
Outcomes: Primary outcome was composite of all
cause mortality, unplanned cardiac surgery, embolic
events or recurrent bacteremia from randomization
until six months after antibiotics were completed
Inclusion Criteria
•
Adults
•
Stable condition with Left sided endocarditis
(native or prosthetic) who met modified Duke
Criteria
•
Culture positive for Strep, E. Faecalis, MSSA
or Coag Neg Staph
•
10 Days of antibiotic therapy needed to
remain
Inclusion Criteria
•
Within 1-3 days of completion of abx, TEE
performed to confirm patient had sufficient
response to therapy
Exclusion Criteria
•
Did not meet Duke’s criteria
•
Species of bacteria
•
Refused to consent
•
High CRP/WBC
•
Abscess at valve
•
Poor gi uptake
•
Others
Study Design
•
Randomized patients in Denmark who were
referred to cardiac centers for IE
•
Non-inferiority trial
•
Estimated event rates from literature for each
of the outcomes
•
Also took blood levels of oral antibiotic
regimen to ensure adequate gi uptake
Study Design
Results
dy Design
Results
dy Design
Results
dy Design
Concerns/Weaknesses
dy Design
•
Patients must have functioning GI tract
•
MRSA not in this study
•
FEW IVDA patients in this study (5!!!)
•
Potential for referral bias
Bottom Line
•
Patients with L sided endocarditis with
streptococcus, E. Faecalis, MSSA or Coag
Neg staph who were clinically stable can
be considered for oral antibiotic therapy
•
Would work closely with ID for follow up
and monitoring plan
Case 1
•
27 yo IVDA is admitted to the hospital with endocarditis. Because
the patient is still doing heroin, many of the providers want the
patient to remain in the hospital for 6 weeks of therapy. The patient
feels well and is independent in spirit and does not want to stay in
the hospital. What do you recommend?
•
A. Discharge the patient with a PICC line home to complete 6 weeks
of therapy
•
B. Pick some oral antibiotic regimen that should work and send him
out
•
C. Make the patient stay in house for 6 weeks for IV therapy
•
D. It Depends
Case 2
•
27 yo Diabetic is admitted to the hospital with osteomyelitis.
The patient is wanting to smoke but your hospital won’t allow
him to leave the floor to do it. The patient feels well and is
independent in spirit and does not want to stay in the hospital.
What do you recommend?
•
A. Discharge the patient with a PICC line home to complete 6
weeks of therapy
•
B. Pick some oral antibiotic regimen that should work and
send him out
•
C. Make the patient stay in house for 6 weeks for IV therapy
•
D. It Depends
Lower Extremity Wound Care at Duke
Article
dy Design
Trial Design
•
Objective: To determine if oral antibiotic
therapy is noninferior to IV antibiotic therapy
for bone or joint infections
•
Design: Multi-center, open label, randomized
controlled non-inferiority trial
•
Outcomes:Definitive treatment failure within 1
year as defined by the following:
Outcomes- Treatment Failure
Microbiologic Confirmation from deep tissue samples
Histologic Confirmation: + micro in specimen
Study Design
dy Design
•
1054 adult patients from UK
•
26 sites
•
5 years
•
Patients would have received at least 6
weeks of IV therapy for acute or chronic bone
or joint infection, osteomylelitis, native joint
infection requiring arthroplasty, prosthetic
joint infection or vertebral osteomyelitis
Study Design
dy Design
Patients were Same
dy Design
Study Design
•
Frequent Assessments at day 42, 120,
365
•
Adherence to treatment assessed at day
14 and 42 using validated tool
Outcomes
Secondary Outcomes
•
More IV catheter complications in IV group
•
More early discontinuation of therapy in IV
group
•
No difference in c dif or ADEs
•
Longer hospital stays for IV group
•
No difference in patient reported outcomes
Antibiotics Used
•
IV Group
•
Glycopeptides 41%
•
Cephalosporins 28%
•
Oral Group
•
Quinolones 44%
•
Combination oral
therapy 14%
Limitations
•
Unclear if effect persists beyond 1 year
•
Open label study
•
Reliance on Infectious Disease specialist
to come up with antibiotic regimen
Bottom Line
•
Oral antibiotic therapy was noninferior to
IV antibiotic therapy when used during first
six weeks of therapy for bone and joint
infections when assessed at one year
•
Oral therapy is associated with shorter
LOS, fewer IV catheter issues
Case 2
•
27 yo Diabetic is admitted to the hospital with osteomyelitis.
The patient is wanting to smoke but your hospital won’t allow
him to leave the floor to do it. The patient feels well and is
independent in spirit and does not want to stay in the hospital.
What do you recommend?
•
A. Discharge the patient with a PICC line home to complete 6
weeks of therapy
•
B. Pick some oral antibiotic regimen that should work and
send him out
•
C. Make the patient stay in house for 6 weeks for IV therapy
•
D. It Depends
Case 3
•
69 yo M with recently diagnosed prostate cancer comes to
your clinic for a routine check up. He is planning to go on a
road trip. You are concerned about his DVT risk. What do
you recommend?
•
A. Tell him to take frequent breaks and ambulate often
•
B. Calculate his risk and prescribe warfarin if risk is high
•
C. Calculate his risk and prescribe enoxaparin if risk is high
•
D. Calculate his risk and prescribe apixaban if risk is high
Khorana Score
Trial Design
•
Objective: To assess the efficacy of
apixiban prophylaxis in ambulatory
patients with cancer at risk for DVT
•
Design: Randomized, placebo controlled
double blinded trial
Outcomes
•
Primary – First episode of VTE (proximal
DVT or PE) within 180 days after
randomization
•
Safety – Major Bleeding
Inclusion Criteria
•
Population: Adults with newly diagnosed
cancer or cancer progression who were
starting chemotherapy for minimum of 3
months.
•
Khorana score >2 or more
Exclusion Criteria
•
High bleeding risk conditions such as liver
disease with coagulopathy, basal or
squamous skin cancer; acute leukemia or
myeloproliferative neoplasm, planned
stem cell transplant, life expectancy less
than 6 months, GFR <30 or plts <50K
•
Contraindication to apixiban
Intervention
•
Apixiban 2.5mg twice daily vs placebo for
180 days
•
First dose administered within 24 hrs of
chemotherapy
Case 3
Points of Interest
•
Most common types of cancer were GYN
25%, Lymphoma 25% and pancreatic 13%
•
Very few patients with colon or prostate
cancers
•
Absolute risk reduction was apixiban was 6%
•
NNT = 17
•
NNH = 59
Bottom Line
•
For ambulatory patients with cancer who
are initiating chemotherapy, DVT
prophylaxis with 2.5 mg apixiban twice
daily resulted in significantly lower risk of
VTE than placebo with increased risk of
major bleeding
Case 3
•
69 yo M with recently diagnosed prostate cancer comes to
your clinic for a routine check up. He is planning to go on a
road trip. You are concerned about his DVT risk. What do
you recommend?
•
A. Tell him to take frequent breaks and ambulate often
•
B. Calculate his risk and prescribe warfarin if risk is high
•
C. Calculate his risk and prescribe enoxaparin if risk is high
•
D. Calculate his risk and prescribe apixaban if risk is high
Case 4
•
A 76 yo M with htn, dm, cad, copd wakes up from sleep with
new R arm weakness. He went to bed 8 hours ago. He is
brought to the ED by EMS. CT imaging is consistent with an
ischemic stroke. What do you recommend?
•
A. No treatment beyond antiplatelet therapy and secondary
prevention due to lack of clarity about onset of stroke
•
B. Statin Therapy
•
C. Consider IV thrombolytic therapy
•
D. All of the above
Time = Brain
Case 4
Case 4
•
Objective: To assess the benefit of IV alteplase given
between 4.5 and 9 hours after stroke onset or on
awakening with stroke symptoms
•
Design: Multi-center, randomized, placebo controlled
•
Primary Outcome: Modified Rankin score of 0-1 at 90
days
•
Secondary Outcome: Rankin Score at 90 days;
Reperfusion percentage of >50% and at least 90% at
24 hours after intervention
Rankin Scale
Trial Design
•
Adult Patients with excellent
functional status before enrollment
•
Presents with Stroke NIHSS score of 4-
26
•
Imaged with CT perfusion imaging or
MRI
•
Excluded if patients were considered
for endovascular intervention
•
Sleep defined as median time between
when patient went to bed and woke
up
Safety Outcomes
Trial Design
•
8 years in 16 centers; Australia, NZ,
Taiwan and Finland
•
225 patients total; average age 73
alteplase group and 71 for placebo;
Results
•
Primary outcome ie better Rankin
Score of 0-1 in 35% of TPA vs 29%
placebo
•
Improved functional independence
at 90 days 24% for TPA vs 10% for
placebo
•
Higher rates of ICH for TPA as
expected but did not reach statistical
significance
Bottom Line
•
Approach to imaging classification in this trial
very different than Wake UP trial increasing
candidates for therapy
•
65% of patients in this study woke up with
Stroke symptoms
•
Consider use of alteplase in patients with
favorable perfusion imaging between 4.5 and
9 hours after stroke onset or awakening
Case 4
•
A 76 yo M with htn, dm, cad, copd wakes up from sleep with
new R arm weakness. He went to bed 8 hours ago. He is
brought to the ED by EMS. CT imaging is consistent with an
ischemic stroke. What do you recommend?
•
A. No treatment beyond antiplatelet therapy and secondary
prevention due to lack of clarity about onset of stroke
•
B. Statin Therapy
•
C. IV thrombolytic therapy
•
D. All of the above
Case 5
•
A 72 yo F with cad, htn, peripheral vascular disease
with recent PCI six months ago comes to you
complaining of having to take too many medications
and that the aspirin and Plavix are increasing her risk
of stomach ulcers. She would like to stop taking both
of them. What do you recommend?
•
A. DAPT is recommended after PCI for 12 months
•
B. Newer stents are so good, you can just stop both
•
C. 6 months is no worse than 12 months so stop the
plavix
Case 5
Trial Design
•
Objective: To show that limiting DAPT to six
months in patients with STEMI is non-inferior to
twelve months of DAPT
•
Design: Prospective, Randomized, multi-centered
non-inferiority trial
•
Outcomes:Composite of Mortality, MI,
Revascularization, Stroke or Thrombolysis, Major
Bleeding at 18 months after randomization (24
months)
Trial Design
•
2011-2015
•
1100 patients enrolled; 870 randomized
•
Groups were balanced
•
Age – 60; 76% male
•
All patients w STEMI treated with PCI with second generation stent
(Resolute)
•
Patients could take DAPT with Asa + clopidogrel or prasugrel or
ticagrelor
•
After six months, patients were randomized to discontinue DAPT
and take ASA only or remain on DAPT for six more months
Results
•
Primary Outcome occurred in
4.8% SAPT and 6.6% of DAPT
•
Non-inferiority was met
Results
•
Second generation stents appear to be much
better
•
Study is consistent with others in that event
rate with new stents remains very low
•
Stopping DAPT does not show a rebound
effect
•
Limitations
•
High risk patients may be removed at six
months
•
Resolute stents only
•
Cardiogenic shock patients not included
Bottom Line
•
First dedicated randomized trial to
compare six vs twelve months of DAPT in
STEMI patients after PCI
•
Limiting DAPT to six months in patients
who are stable results in a non-inferior
outcome
Case 5
•
A 72 yo F with cad, htn, peripheral vascular disease
with recent PCI six months ago comes to you
complaining of having to take too many medications
and that the aspirin and Plavix are increasing her risk
of stomach ulcers. She would like to stop taking both
of them. What do you recommend?
•
A. DAPT is recommended after PCI for 12 months
•
B. Newer stents are so good, you can just stop both
•
C. 6 months is no worse than 12 months so stop the
plavix
Case 6
•
Your 72 yo patient did not stop DAPT therapy after doing
some reading on the internet despite what you told her. She
is admitted 3 months later with an intracerebral hemorrhage.
You notice she has cad and peripheral vascular disease and
are worried that she still needs some antiplatelet therapy.
What do you tell her since she has just her an ICH?
•
A. The risk of re-bleeding is too high to ever take antiplatelets
again.
•
B. Consult neurology to decide
•
C. Tell her to stop antiplatelets for about 3 months and then
consider resuming them
Case 6
Trial Design
•
Objective: To assess the effects of restarting or
avoiding anti-platelet therapy on recurrent
symptomatic ICH and whether this risk may exceed
any reduction of occlusive vascular events.
•
Study Design: Prospective, randomized, open label,
blinded endpoint trial
•
Outcomes: Primary: Recurrent symptomatic ICH for up
to 5 years; Secondary: Composite of all major
hemorrhagic events and composite of all major
vascular occlusive events
Trial Participants
•
Aimed to recruit 720
•
562 participants from 122 hospital sites
•
Average Age was 76; mostly Male and
92% Caucasian
•
62% lobar ICH
•
88% had previous occlusive vascular
disease
•
75% - had HTN
•
25% - had DM
•
25% - had afib
•
50% on asa, 25% on Plavix
Trial Design
•
Followed up with PCPs and surveyed
participants was near perfect
•
Good adherence to treatment
•
Followed patients for 4 years
Results
Case 6
Case 6
Bottom Line
•
This study provides reassurance that
restarting antiplatelet drugs after 76 days
after an intracerebral hemorrhage seems
to be relatively safe especially when
viewed in light of an overall reduction of
non fatal MI, stroke and death from
vascular causes.
Case 6
•
Your 72 yo patient did not stop DAPT therapy after doing
some reading on the internet despite what you told her. She
is admitted 3 months later with an intracerebral hemorrhage.
You notice she has cad and peripheral vascular disease and
are worried that she still needs some antiplatelet therapy.
What do you tell her since she has just her an ICH?
•
A. The risk of re-bleeding is too high to ever take antiplatelets
again.
•
B. Consult neurology to decide
•
C. Tell her to stop antiplatelets for about 3 months and then
consider resuming them
Case 7
•
A 88 yo M presents to the ED with chest pain. His oxygen
saturation is 94%. He is delirious. Nursing is wrestling with
him to keep his oxygen on. What do you tell the nurses to
do?
•
A. Leave him off oxygen as there is no benefit in AMI at his
current saturation
•
B. Restrain him and put oxygen on.
•
C. Sedate him with some Haldol to get oxygen therapy on
•
D. Everyone gets oxygen in the ED so help the nurse
convince the patient to wear oxygen.
Too Much of a Good Thing?
Too Much of a Good Thing
Case 7
Trial Design
•
Objective: Review randomized controlled
trials investigating the efficacy and safety
of liberal versus conservative oxygen
therapy in acutely ill adults.
•
Design:Systematic Review and
Metanalysis
Outcomes
•
Mortality (30 day, in hospital and at follow
up)
•
Morbidity(disability, risk of HA Pneumonia,
Risk of HAI and hospital length of stay)
Trial Design
•
Search identified 1784 records
•
Yielded 25 RCTs
•
16037 patients with critical illness, stroke, MI,
cardiac arrest or patient with emergent
surgery
•
Median age 64; 64% male; Median follow up
3 months
Results
Results
Results
Why?
•
Vasoconstriction, inflammation and
oxidative stress on pulmonary,
cardiovascular and neurological systems
Case 7
•
Findings are consistent with other meta-
analysis
•
Consistent with other more recent studies
that show that overly aggressive treatment
of physiological parameters can lead to
harm (blood and glucose)
Not Surgery Populations?
•
CDC and WHO strongly
recommend increased FIO2 during
surgery and immediate post op period to
reduce risk of surgical site infections
Bottom Line
•
This systematic review and metanalysis
concludes that too much oxygen is
potentially life threatening. Liberal oxygen
therapy is not beneficial for acute illnesses
New Guidelines Offered
New Guidelines
Do You Want the ER Combo?
Oxygen
Guidelines
Guidelines
Case 7
•
A 88 yo M presents to the ED with chest pain. His oxygen
saturation is 94%. He is delirious. Nursing is wrestling with
him to keep his oxygen on. What do you tell the nurses to
do?
•
A. Leave him off oxygen as there is no benefit in AMI at his
current saturation
•
B. Restrain him and put oxygen on.
•
C. Sedate him with some Haldol to get oxygen therapy on
•
D. Everyone gets oxygen in the ED so help the nurse
convince the patient to wear oxygen.
What We Learned
•
Patients with L sided endocarditis with streptococcus,
E. Faecalis, MSSA or Coag Neg staph who were
clinically stable can be considered for oral antibiotic
therapy
•
Oral antibiotics for osteomyelitis may be just as good
as IV antibiotics
•
For patients with cancer who are in the ambulatory
setting with high risk for DVT, apixaban may reduce
the risk of VTE but with higher risks of bleeding
What We Learned
•
The stroke treatment window is getting bigger
(may be up to 9 hours now)
•
DAPT after PCI can be limited to six months now
•
Antiplatelet therapy after ICH is probably safe to
resume after about 2.5 months
•
Although previously thought to be relatively
benign, oxygen therapy for acute medical
conditions is potentially dangerous
Questions?
An active heroin user with endocarditis raises the question - should the patient stay in the hospital for IV therapy or be discharged with oral antibiotics? A randomized trial explores the feasibility of switching to oral antibiotics with similar outcomes. Inclusion criteria detail stability requirements and culture positivity, while exclusion criteria specify factors that preclude participation. The ultimate decision depends on individual patient factors and balancing risks and benefits.
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Presentation Transcript
Hot Topics in Hospital Medicine 2019 Noppon Setji Hilton Head SC
Disclosures None Lack of proven scientific method
Case 1 27 yo Male who is an active heroin user is admitted to the hospital with endocarditis. Because the patient is still doing heroin, many of the providers want the patient to remain in the hospital for 6 weeks of therapy. The patient feels well and is independent in spirit and does not want to stay in the hospital. What do you recommend? A. Discharge the patient with a PICC line home to complete 6 weeks of therapy B. Pick some oral antibiotic regimen that should work and send him out C. Make the patient stay in house for 6 weeks for IV therapy D. It Depends
Trial Design Objectives: To evaluate whether patients with left sided infective endocarditis could be switched to an oral antibiotic regimen that would result in similar outcomes Design:Multi-center; randomized, Non-inferiority Trial Outcomes: Primary outcome was composite of all cause mortality, unplanned cardiac surgery, embolic events or recurrent bacteremia from randomization until six months after antibiotics were completed
Inclusion Criteria Adults Stable condition with Left sided endocarditis (native or prosthetic) who met modified Duke Criteria Culture positive for Strep, E. Faecalis, MSSA or Coag Neg Staph 10 Days of antibiotic therapy needed to remain
Inclusion Criteria Within 1-3 days of completion of abx, TEE performed to confirm patient had sufficient response to therapy
Exclusion Criteria Did not meet Duke s criteria Species of bacteria Refused to consent High CRP/WBC Abscess at valve Poor gi uptake Others
Study Design Randomized patients in Denmark who were referred to cardiac centers for IE Non-inferiority trial Estimated event rates from literature for each of the outcomes Also took blood levels of oral antibiotic regimen to ensure adequate gi uptake
Results dy Design
Results dy Design
Results dy Design
Concerns/Weaknesses dy Design Patients must have functioning GI tract MRSA not in this study FEW IVDA patients in this study (5!!!) Potential for referral bias
Bottom Line Patients with L sided endocarditis with streptococcus, E. Faecalis, MSSA or Coag Neg staph who were clinically stable can be considered for oral antibiotic therapy Would work closely with ID for follow up and monitoring plan
Case 1 27 yo IVDA is admitted to the hospital with endocarditis. Because the patient is still doing heroin, many of the providers want the patient to remain in the hospital for 6 weeks of therapy. The patient feels well and is independent in spirit and does not want to stay in the hospital. What do you recommend? A. Discharge the patient with a PICC line home to complete 6 weeks of therapy B. Pick some oral antibiotic regimen that should work and send him out C. Make the patient stay in house for 6 weeks for IV therapy D. It Depends
Case 2 27 yo Diabetic is admitted to the hospital with osteomyelitis. The patient is wanting to smoke but your hospital won t allow him to leave the floor to do it. The patient feels well and is independent in spirit and does not want to stay in the hospital. What do you recommend? A. Discharge the patient with a PICC line home to complete 6 weeks of therapy B. Pick some oral antibiotic regimen that should work and send him out C. Make the patient stay in house for 6 weeks for IV therapy D. It Depends
Article dy Design
Trial Design Objective: To determine if oral antibiotic therapy is noninferior to IV antibiotic therapy for bone or joint infections Design: Multi-center, open label, randomized controlled non-inferiority trial Outcomes:Definitive treatment failure within 1 year as defined by the following:
Outcomes- Treatment Failure Microbiologic Confirmation from deep tissue samples Histologic Confirmation: + micro in specimen
Study Design dy Design 1054 adult patients from UK 26 sites 5 years Patients would have received at least 6 weeks of IV therapy for acute or chronic bone or joint infection, osteomylelitis, native joint infection requiring arthroplasty, prosthetic joint infection or vertebral osteomyelitis
Study Design dy Design
Patients were Same dy Design
Study Design Frequent Assessments at day 42, 120, 365 Adherence to treatment assessed at day 14 and 42 using validated tool
Secondary Outcomes More IV catheter complications in IV group More early discontinuation of therapy in IV group No difference in c dif or ADEs Longer hospital stays for IV group No difference in patient reported outcomes
Antibiotics Used IV Group Glycopeptides 41% Cephalosporins 28% Oral Group Quinolones 44% Combination oral therapy 14%
Limitations Unclear if effect persists beyond 1 year Open label study Reliance on Infectious Disease specialist to come up with antibiotic regimen
Bottom Line Oral antibiotic therapy was noninferior to IV antibiotic therapy when used during first six weeks of therapy for bone and joint infections when assessed at one year Oral therapy is associated with shorter LOS, fewer IV catheter issues
Case 2 27 yo Diabetic is admitted to the hospital with osteomyelitis. The patient is wanting to smoke but your hospital won t allow him to leave the floor to do it. The patient feels well and is independent in spirit and does not want to stay in the hospital. What do you recommend? A. Discharge the patient with a PICC line home to complete 6 weeks of therapy B. Pick some oral antibiotic regimen that should work and send him out C. Make the patient stay in house for 6 weeks for IV therapy D. It Depends
Case 3 69 yo M with recently diagnosed prostate cancer comes to your clinic for a routine check up. He is planning to go on a road trip. You are concerned about his DVT risk. What do you recommend? A. Tell him to take frequent breaks and ambulate often B. Calculate his risk and prescribe warfarin if risk is high C. Calculate his risk and prescribe enoxaparin if risk is high D. Calculate his risk and prescribe apixaban if risk is high
Trial Design Objective: To assess the efficacy of apixiban prophylaxis in ambulatory patients with cancer at risk for DVT Design: Randomized, placebo controlled double blinded trial
Outcomes Primary First episode of VTE (proximal DVT or PE) within 180 days after randomization Safety Major Bleeding
Inclusion Criteria Population: Adults with newly diagnosed cancer or cancer progression who were starting chemotherapy for minimum of 3 months. Khorana score >2 or more
Exclusion Criteria High bleeding risk conditions such as liver disease with coagulopathy, basal or squamous skin cancer; acute leukemia or myeloproliferative neoplasm, planned stem cell transplant, life expectancy less than 6 months, GFR <30 or plts <50K Contraindication to apixiban
Intervention Apixiban 2.5mg twice daily vs placebo for 180 days First dose administered within 24 hrs of chemotherapy
Points of Interest Most common types of cancer were GYN 25%, Lymphoma 25% and pancreatic 13% Very few patients with colon or prostate cancers Absolute risk reduction was apixiban was 6% NNT = 17 NNH = 59
Bottom Line For ambulatory patients with cancer who are initiating chemotherapy, DVT prophylaxis with 2.5 mg apixiban twice daily resulted in significantly lower risk of VTE than placebo with increased risk of major bleeding
Case 3 69 yo M with recently diagnosed prostate cancer comes to your clinic for a routine check up. He is planning to go on a road trip. You are concerned about his DVT risk. What do you recommend? A. Tell him to take frequent breaks and ambulate often B. Calculate his risk and prescribe warfarin if risk is high C. Calculate his risk and prescribe enoxaparin if risk is high D. Calculate his risk and prescribe apixaban if risk is high
Case 4 A 76 yo M with htn, dm, cad, copd wakes up from sleep with new R arm weakness. He went to bed 8 hours ago. He is brought to the ED by EMS. CT imaging is consistent with an ischemic stroke. What do you recommend? A. No treatment beyond antiplatelet therapy and secondary prevention due to lack of clarity about onset of stroke B. Statin Therapy C. Consider IV thrombolytic therapy D. All of the above
