Thread by @ChrisDJacksonMD

Hey #medtwitter! I am giving a go at my first #MedEd #Tweetorial! I want to review my top 10 trials of 2019 inspired by my talk @UTHSC_Medicine on 2019 GIM updates. Thanks to @cjchiu for the inspiration and encouragement to do this!

1) POC CRP to Guide Antibiotic Treatment for COPD trial:
- RCT of 636 patients with GOLD stage II COPD seen at 86 clinics for AECOPD
- 20.4% absolute difference in self-reported abx use with no difference in COPD-related health at 4 weeks
- Maybe a CRP a day keeps the abx away

POC CRP to Guide Antibiotic Treatment Limitations:
- May not be generalizable to patients with more advanced COPD
- Bias reporting by patients
- Not all places have POC CRP available
- Read more here: nejm.org/doi/full/10.10…

2) DAPA HF trial:
- RCT of 4744 patients with mostly NYHA class II HF
- Receive dapaglifozin + usual care or placebo + usual care
- 4.9% decrease in composite of worsening HF or CV death events with dapagliflozin (NNT = 20)

DAPA HF trial limitations:
- May not be generalizable to patients with class III or IV HF
- Use of ACEI/BB across study population inconsistent
- Low baseline use of sacubitril-valsartan
- Read more here: nejm.org/doi/full/10.10…

3) PIONEER6 trial:
- Non-inferiority RCT of 3183 patients with DM & high CV risk
- Received oral semaglutide or placebo + usual care
- 1% fewer MACE with oral semaglutide use compared to placebo over 15.9 months of trial
- Thus, no excess CV risk with use of oral semaglutide

PIONEER6 limitations:
- Low numbers of MACE compared to previous GLP1 CVOTs
- Large non-inferiority margin (up to 80% excess CV risk)
- Higher discontinuation rates of semaglutide vs. placebo due to GI side effects (6.8% vs. 1.6%)
- Read more here: nejm.org/doi/full/10.10…

4) Canagliflozin & Renal Outcomes in Type 2 DM & Nephropathy:
- RCT of 4401 patients w/ Type 2 DM & stage 2 or more CKD w/ albuminuria
- Primary outcome: composite of ESRD, doubling of SCr, or death from renal/CV causes
- 30% relative decrease in primary outcome w/ canagliflozin

Canagliflozin & Renal Outcomes in Type 2 DM & Nephropathy Limitations:
- Trial stopped early, which can reduce power to detect significant differences
- Excluded patients with advanced CKD (stage 4 or greater)
- Read more here:
nejm.org/doi/full/10.10…

5) Cardiovascular Events & White Coat Hypertension (WCH):
- Meta-analysis of 27 trials evaluating CV risk of WCH or treated white coat effect (WCE)
- 33% increase in all-cause mortality w/ WCH
- 36% increase in CV events w/ WCH
- Treated WCE may attenuate effect of WCH

Cardiovascular Events and WCH Meta-analysis Limitations:
- Few studies evaluated isolated CV events
- Paucity of data on participant demographics
- Composed of mostly observational studies so residual confounding can not be excluded
- Read more here:
annals.org/aim/article-ab…

6) Torsemide vs Furosemide for HF Meta-analysis:
- 19 studies with 19,280 HF patients
- Outcomes: NYHA functional class CV death, HF hospitalizations
- 7.8% absolute decrease in HF hospitalizations & 14.5 improvement in functional status w/ torsemide use versus furosemide

Torsemide vs Furosemide in HF Meta-Analysis Limitations:
- Fewer HF hospitalizations was not statistically significant
- Wide confidence interval for improvement in functional status when looking at RCTs only
- Read more here:
ajconline.org/article/S0002-…

7) E-cigarettes versus Nicotine Replacement Therapy (NRT):
- RCT of 886 patients wanting to stop smoking in UK
- Randomized to e-cigarette or NRT + behavioral counseling
- 8% increase abstinence at 1 year with vaping vs NRT
- Pts who vape more likely to continue use after 1 year

E-cigarettes vs. NRT trial limitations:
- Open-label design may select for more motivated participants
- Unclear impact of behavioral counseling on outcomes given both groups in the trial received it
- Read more here:
nejm.org/doi/full/10.10…

8) PEGeD study:
- Prospective study of 2017 outpatients with low pretest probability (PTP) for PE
- Evaluated if PE ruled out if low PTP and d-dimer < 1000 ng/mL or moderate PTP and d-dimer < 500 ng/mL
- 19.6% reduction in chest imaging using PEGeD algorithm

PEGeD study limitations:
- Mostly outpatient population who likely have a lower PTP for PE to start
- No clear comparison to standard care
- Read more here:
nejm.org/doi/full/10.10…

9) HYGIA Chronotherapy Trial:
- Multi-center RCT of 19,084 HTN patients in primary care
- Randomized pts to take all BP meds in morning or evening
- Taking BP meds in evening assoc. with 45% decrease in primary CVD outcome (CV death, MI, HF, CVA, coronary revascularization)

HYGIA Chronotherapy Trial Limitations:
- Randomization method in trial not explicitly stated
- Unclear standard treatment for two groups
- Feasibility of intervention in patients with diuretic-based treatment regimens
- Read more here:
academic.oup.com/eurheartj/adva…

10) INFINITY trial:
- RCT of 199 patients > 75 years old w/ HTN & white matter lesions (WML) on imaging
- Randomized to intensive (SBP < 130) or standard (SBP < 145) BP tx
- Intensive tx led to accrual of less WML w/o change in gait speed or executive functioning

INFINITY Trial Limitations:
- Low sample size
- Follow-up of three years may not be long enough to detect differences in cognitive and mobility outcomes
- Read more here:
ahajournals.org/doi/10.1161/CI…

Let's summarize....

Hope you enjoyed this tweetorial!
@EvidenceBasedMD @CPSolvers @thecurbsiders @Back2BasicsDoc @uthsc @UTHSC_Medicine @natesumMRSA @gradydoctor @DxRxEdu @rabihmgeha @3owllearning @GIMaPreceptor @drjoelraja @ETSshow