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TEACHING TOPICS from the New England Journal of Medicine
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Teaching Topics | October 4, 2012
Intraaortic Balloon in Cardiogenic Shock: What were the results of this study, which compared intraaortic balloon counterpulsation or no intraaortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction?
Intricate Interplay: What are the two types of autoimmune hepatitis?
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Teaching Topic
Intraaortic Balloon in Cardiogenic Shock
Original Article
H. Thiele and Others
 
In current international guidelines, intraaortic balloon counterpulsation (IABP) is considered to be a class I treatment for cardiogenic shock complicating acute myocardial infarction. However, evidence is based mainly on registry data, and there is a paucity of randomized clinical trials.
Clinical Pearls
 What were the results of this study, which compared intraaortic balloon counterpulsation or no intraaortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction?
At 30 days, mortality was similar among patients in the IABP group and those in the control group (39.7% and 41.3%, respectively; relative risk with IABP, 0.96; 95% confidence interval, 0.79 to 1.17; P=0.69).
Table 3.Clinical Outcomes.
Figure 1. Time-to-Event Curves for the Primary End Point.
Among patients who received IABP, did results differ between those who had the IABP inserted before versus after revascularization?
Among patients in the IABP group, there was no significant difference in mortality between the patients (13.4%) in whom the balloon pump was inserted before revascularization and the patients (86.6%) in whom the balloon pump was inserted after revascularization (mortality, 36.4% and 36.8%, respectively; P=0.96).
Morning Report Questions
Q. Did safety end points differ between the two groups?
A. There were no significant differences between the IABP group and the control group with respect to the rates of stroke, bleeding, sepsis, or peripheral ischemic complications requiring intervention in the hospital. There were also no significant differences in the rates of reinfarction or stent thrombosis.
Q. How do the authors explain the effect of intraaortic balloon counterpulsation in this trial on the factors that are known to cause death in patients with cardiogenic shock?
A. Death in patients with cardiogenic shock can result from one or more of three factors: hemodynamic deterioration, occurrence of multiorgan dysfunction, and development of the systemic inflammatory response syndrome. There was no immediate improvement in blood pressure or heart rate among patients in whom an intraaortic balloon pump was inserted, as compared with those who did not have a balloon pump inserted. Although there was a positive effect of intraaortic balloon counterpulsation on multiorgan dysfunction at day 2 and day 3, this effect was not evident at day 4. There were also no significant effects on C-reactive protein level or serum lactate level, which were assessed as measures of inflammation and tissue oxygenation. Experimental and clinical studies have indicated that intraaortic balloon counterpulsation results in a hemodynamic benefit as a result of afterload reduction and diastolic augmentation with improvement in coronary perfusion. The authors postulate that the effects on cardiac output are modest and might not be sufficient to reduce mortality.
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Teaching Topic
Intricate Interplay
Clinical Problem-Solving
R.H. Moseley and Others
Although generally regarded as a chronic liver disease, autoimmune hepatitis is manifested as an acute illness in about 25% of patients.
Clinical Pearls
What is the differential diagnosis for severe aminotransferase elevations?
In contrast to the broad differential diagnosis for elevations in serum aminotransferase levels that are less than 5 times the upper limit of the normal range, the causes of severe aminotransferase elevations (>20 times the upper limit of the normal range) are more limited and include Wilson’s disease, acute biliary obstruction, and viral, toxic, ischemic, and autoimmune hepatitis.
What are the two types of autoimmune hepatitis?
Two types of autoimmune hepatitis have been proposed; type 1 is defined by positive results on testing for antinuclear antibodies and smooth-muscle antibodies, and type 2 by positive results on testing for antibodies against liver–kidney microsome type 1 and liver cytosol type 1. Type 2 autoimmune hepatitis has been described mainly in children in Europe and is rare in the United States. Among patients with type 1 disease, the reported prevalence of antinuclear antibodies alone is 13%, smooth-muscle antibodies alone 33%, and both 54%. Autoantibodies develop later in the disease in some patients who are seronegative on initial evaluation. Autoantibody-negative autoimmune hepatitis is important to recognize because patients with this condition typically have a favorable response to glucocorticoid therapy.
Morning Report Questions
Q. What is the standard treatment for severe cases of autoimmune hepatitis?
A. Treatment with either prednisone alone (at a dose of 60 mg daily) or a combination of prednisone (at a dose of 30 mg daily) and azathioprine (at a dose of 50 mg, or 1 to 2 mg per kilogram of body weight, daily) is recommended in cases of severe autoimmune hepatitis, on the basis of data from randomized clinical trials; combination therapy is generally preferred because the lower dose of glucocorticoid reduces side effects. Prednisolone in equivalent doses can be substituted for prednisone. Glucocorticoids are tapered over a 4-week period to a level required to maintain a biochemical remission, and this maintenance regimen is then continued until disease resolution (defined as biochemical remission for a minimum of 24 months), unless there is treatment failure or drug toxicity.
Q. What are the characteristics of nonalcoholic fatty liver disease?
A. Nonalcoholic fatty liver disease is one of the most common causes of asymptomatic aminotransferase elevations and chronic liver disease in Western countries. It encompasses a spectrum of disorders, from simple steatosis to fibrosing steatohepatitis that can progress to cirrhosis and its complications, including hepatocellular carcinoma. Aminotransferase levels can wax and wane, often into the normal range. Associated features include insulin resistance, central adiposity, dyslipidemia, and hypertension. The diagnosis of nonalcoholic fatty liver disease requires that there is no history of substantial alcohol consumption, although the definition of substantial alcohol consumption and the effect of obesity on thresholds for the development of alcoholic fatty liver disease remain unclear. Statins can be safely used in patients with nonalcoholic fatty liver disease and, in the majority of patients with this condition, are associated with improvement in liver enzyme abnormalities.
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