The Pulse - 2024 In Review

In this special edition, we examine:

Top 10+, practice-changing studies for hospitalists in 2024

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1. Bacteremia Breakthrough: Cutting the Antibiotic Cord at Day 7 

   This multinational trial confirms that a 7-day course of antibiotics is just as effective as 14-day course for uncomplicated bacteremia (70% Gram-negative; 17% non-Staph Gram positive). Notable exclusions from this study were patients with S. aureus, neutropenia, severe immunocompromise, prosthetic heart valves or endovascular grafts. The BALANCE Investigators. N Engl J Med 2024 Nov 20.  

   Study Type: multicenter (74), multinational (7) noninferiority trial of 3608 hospitalized patients randomized to 7 vs 14 days of antibiotics for bacteremia; 55% in ICU and 21% on vent  

   Link: https://doi.org/10.1056/NEJMoa2404991  

2. Correcting Hyponatremia: The Goldilocks Zone 

   Correcting severe hyponatremia at a rate of 8–12 mEq/L per 24 hours reduces mortality without increasing the risk of osmotic demyelination syndrome, challenging traditional guidelines favoring slower correction. Faster correction also leads to shorter LOS. Ayus JC et al. JAMA Intern Med 2024 Nov 18.  

   Study Type: a meta analysis involving 16 studies with 11,811 patients with moderate certainty results

   Link: https://doi.org/10.1001/jamainternmed.2024.5981 

3. Newly MINTed Transfusion Threshold for Type 1 MI  

   For myocardial infarction (MI) patients, the MINT trial's latest sub-analysis indicates that aiming for a hemoglobin (Hb) level around 9 g/dL hits a sweet spot, nearly mirroring the outcomes of the higher 10 g/dL threshold but without draining the blood bank. Lowering the threshold to 9 g/dL in type 1 MI could reduce unnecessary transfusions without compromising care. Portela GT et al. Ann Intern Med 2024 Oct 1.  

   Study Type: Prespecified secondary analysis of the MINT trial – an international multicenter (144) of 3492 patients.  

   Link: https://doi.org/10.7326/M24-0571 

4. Jump on the TRAIN: Higher Hemoglobin Threshold on Track for Better Outcomes in Brain Injury 

   For critically ill patients with acute brain injury, it turns out "more is better" when it comes to hemoglobin. The TRAIN trial reveals that patients transfused to a higher hemoglobin threshold (≥9 g/dL) fared better neurologically at six months, with fewer cerebral infarctions compared to those kept at lower levels. So, while most ICU patients still do fine with a hemoglobin target of <7 g/dL, neurocritically ill patients may need that extra boost. Taccone FS et al. JAMA 2024 Oct 9.  

   Study Type: international, multicenter, open-label, randomized clinical trial conducted in 72 ICUs across 22 countries with 850 patients 

   Link: https://doi.org/10.1001/jama.2024.20424

5. Finerenone for Patients with Heart Failure and Preserved or Mildly Reduced Ejection Fraction 

   Finerenone (sMRA) flexes its heart-saving muscles in reducing hospitalizations for heart failure with preserved or mildly reduced ejection fraction, but with spironolactone in the wings at a fraction of the cost, it’s a showdown worth watching. Solomon SD et al. N Engl J Med 2024 Sep 1.

   Trial Type: manufacturer-funded, placebo, randomized FINEARTS-HF trial with 6001 patients followed over 32 months  

   Link: https://doi.org/10.1056/NEJMoa2407107

6. Introducing PREVENT: The AHA’s Comprehensive CV Risk Calculator

   Meet PREVENT, the AHA’s new cardiovascular risk calculator that’s taking on the 2013 ASCVD tool with a broader and more holistic approach. While the old calculator just gave you ASCVD risk, PREVENT goes the extra mile by offering separate estimates for overall cardiovascular disease, ASCVD (including stroke), and heart failure. Plus, it provides 10-year risk for those aged 30-79 and a 30-year risk for younger folks (30-59). It also includes BMI, kidney function, and zip code for social context—though it predicts much lower risks across the board.

   Source: https://professional.heart.org/en/guidelines-and-statements/prevent-calculator

7. Don’t Sweat It: New Rules Say to Chill on High BP Without Symptoms

   The American Heart Association (AHA) has released its first guidelines for managing asymptomatic elevated blood pressure (BP) in hospitalized patients, emphasizing caution to avoid overtreatment. The guidance recommends addressing reversible causes and generally avoiding aggressive treatment unless there's evidence of target-organ damage, reserving medication adjustments for outpatient follow-up when appropriate. This shift aims to prevent unnecessary interventions and medication intensification at discharge.

   Source: https://doi.org/10.1161/HYP.0000000000000238

8. Gut Check: Pre-Op Prep for Patients on GLP-1 Agonists

   GLP-1 agonists appear to be all the rage. So don’t get caught clueless when your inpatient pre-op consults start asking what to do with the med. The concern is that GLP-1 agonists cause delayed gastric emptying which increases aspiration risk during procedures with sedation. New multi-society guidelines advise hospitalists to stratify patients’ risk: continue GLP-1s for low-risk patients but hold doses for high-risk patients—those in dose escalation, with GI symptoms, or dysmotility risk factors. A liquid diet 24 hours pre-op and point-of-care gastric ultrasounds are suggested for high-risk or unassessed patients. While data remain limited, this guidance offers a balanced, cautious approach for perioperative management.

   Source: https://www.cghjournal.org/article/S1542-3565(24)00910-8/fulltext

9. All Hail LR, King of Fluids

   In the latest showdown of IV fluids, Lactated Ringer's solution continues to prove its dominance over normal saline now in managing sickle cell vaso-occlusive crises. Not only does LR boost hospital-free days and shorten stays, but it also keeps the sickling drama at bay. Alwang AK et al. JAMA Intern Med 2024 Sep 9.

   Study Type: multicenter retrospective cohort study 

   Link: https://doi.org/10.1001/jamainternmed.2024.4428