Episode 238: 238. What to do With Low Risk Pulmonary Embolism?

NNT of 21 over 18 months to prevent a composite of worsening heart failure or cardiovascular death

NNT for hospitalization = 27

NNT for Cardiovascular Death = 53

N Engl J Med 2019; 381:1995-2008

Dapagliflozin and HFpEF did happen to improve the composite outcome but this was based mainly on hospitalizations not on death and comes at a big price tag with the NNT around 36 at 2.3yrs. 

N Engl J Med 2022; 387:1089-1098

Hospitalization for heart failure occurred in 8.6% of patients in the empagliflozin group and 11.8% patients in the placebo group (hazard ratio, 0.71; 95% CI, 0.60 to 0.83)

number needed to treat [NNT] = 32 per 26 months

 
But the drug company did a great job of writting the paper so you think there is mortality benefit

https://www.nejm.org/doi/full/10.1056/NEJMoa2107038

EMPA-REG OUTCOME back in 2015 this was the first SGLT2 trial to set the world on fire with Primary Outcome: 

death from cardiovascular causes: NNT 46 per 3.1 yrs (at $600 a month, 1 million dollars per life saved)

nonfatal myocardial infarction: NS∞

nonfatal stroke: NS∞

https://www.nejm.org/doi/full/10.1056/nejmoa1504720

Forty-two percent of patients had a PPI on their medication list without indication 8 weeks after discharge, and more than half of these patients still were using PPIs 1 year later.

Compared with propensity-score matched patients without PPI use after discharge, patients with continued PPI use were 27% more likely to develop pneumonia, 17% more likely to develop experience cardiac events, 34% more likely to be .readmitted to the hospital in the subsequent year and 17% greater risk of in increased mortality at two years.

https://journals.lww.com/ccmjournal/fulltext/2024/02000/timely_cessation_of_proton_pump_inhibitors_in.4.aspx

These results are reassuring for management of both underweight and overweight patients with AF.

That said, I would still have reservations about prescribing DOACs in the small minority of patients with BMI >45 kg/m2 or body weight >330lbs due to their underrepresentation in the pivotal trials and when you look at the supplementary data you will see a weight of 262 was 95% tile so >330 would be around the 99th %tile of weight.


https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.123.066279

Nurse Practitioners prescribe medications off the beers list at the same rate at primary care physicians, hard to tell what this means for patient care and patient outcomes. 


https://www.acpjournals.org/doi/10.7326/M23-0827?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Using the Brain Care Score seem to be effective in predicting the risk of dementia

• For participants under 50, each five-point higher BCS is associated with a 50% lower risk of dementia or stroke
• For participants under 50, each five-point higher BCS is associated with a 59% lower risk of dementia 
  
  THE SCORE IS HERE ---->. https://www.massgeneral.org/assets/mgh/pdf/neurology/mccance-center/brain-care-score.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10725202/#:~:text=A%20five%2Dpoint%20higher%20BCS,%25)%20among%20those%20aged%20%3E59.

Even when starting DAPT within 72hours of symptom onset for individuals with minor stroke or TIA the benefit of DAPT for the first 21 days was still seen at 90 day follow up in the form of less recurrent stroke

https://www.nejm.org/do/10.1056/NEJMdo007334/full/

In those high risk patients -- usually with lung or GI cancer they did benefit from primary prevention VTE prophalaxis with a NNT of 6-7 for VTE and death at 6 months. 

https://pubmed.ncbi.nlm.nih.gov/37733336/#:~:text=Conclusions%20and%20relevance%3A%20In%20this,safety%20concerns%2C%20and%20with%20reduced