Highlights for Monday, May 2

We are starting Monday with 3 publications chosen as suggested reading by McMaster editors.

Prognosis and management in patients with TIA or minor stroke

In this cohort study, over 4,000 patients who suffered a transient ischemic attack (TIA) or minor stroke within previous 7 days and who were managed in systems dedicated to urgent evaluation were followed for 1 year. About three-quarters of patients were seen by a stroke specialist within 24 hours of symptom onset and were admitted to the hospital for an average of 4 days. The study run from 2009 to 2011 and provided information on such issues as patient prognosis and management.

The risk of stroke (re)occurrence was 1.5% at day 2, 2.1% at day 7, 2.8% at day 30, and 5.1% at 1 year (about half of what was reported in the past). A higher risk was associated with an age over 60 years, a blood pressure level of 140/90 mm Hg or higher, the presence of unilateral weakness or speech disturbance, diabetes mellitus, and duration of symptoms over 60 minutes.

At entry to the study, about 70% of patients had history of hypertension, and a similar proportion had hyperlipidemia. Diabetes was present in 20% of patients. Five percent of patients had a new diagnosis of atrial fibrillation, in addition to about 10% who had had it before. A carotid stenosis of over 50% was found in 15% of patients, and about 25% of them underwent revascularization prior to discharge.

At discharge, 70% of patients were treated with at least 1 antihypertensive drug and a similar proportion with a lipid-lowering medication (mostly statin). Over 90% of patients were on an antiplatelet drug (two-thirds received acetylsalicylic acid) and 17% were anticoagulated.

Diabetes medications: monotherapy or metformin-based combination therapy for type 2 diabetes

In this systematic review, the authors compared different medications used as monotherapy or part of metformin-based combination treatment for type 2 diabetes mellitus.

The authors observed that metformin was associated with reduced cardiovascular mortality in comparison to sulfonylureas. Reduction in the hemoglobin A_1c level was similar across different drugs, except for the smaller effect of dipeptidyl peptidase-4 (DPP-4) inhibitors. Patients’ body weight was increased with the use of insulin and sulfonylureas but maintained or decreased with the use of metformin, DPP-4 inhibitors, glucagon-like peptide-1 (GLP-1) receptor antagonists, and sodium-glucose cotransporter 2 (SGLT-2) inhibitors.

The effect of adding an additional drug to metformin was similar to that achieved with that drug used as monotherapy.

A simple outcome score in patients with ARDS

An ICU-based study examined over 600 patients with moderate to severe acute respiratory distress syndrome (ARDS). It classified patients according to age (<47 years, 1 point; 47-66 years, 2 points; >66 years, 3 points), the PaO₂/FiO₂ ratio (>158, 1 point; 105-158, 2 points; <105, 3 points), and plateau pressure (<27 cm H₂O, 1 point; 27-30 cm H₂O, 2 points; >30 cm H₂O, 3 points).

The overall hospital mortality was over 40%, with major differences depending on the above score (range, 3-9 points). One-month mortality in those with scores 3-4 was less than 10%; in those with 5-6 points, 30%; and in those with 7-8 points, 70%. Respective mortality at 2 months ranged from 15% through 40% to 80%. Those observations may help clinicians and patients as well as families in prognostication and decision-making.

In this observational study, a lower tidal volume (<6.7 mL/kg of predicted weight vs >7.8 mL/kg) was associated with lower mortality (42% vs 54%), as was ventilation with a higher respiratory rate (RR) (38% mortality among those with a RR >26 vs 53% among those with a RR <21), providing additional support for lung-protective ventilation.