Gynecology

A new evidence-based guideline on how to identify and treat patients with nonvalvular atrial fibrillation to prevent cardioembolic stroke from the American Academy of Neurology suggests when to conduct cardiac rhythm monitoring and offer anticoagulation, including newer agents in place of warfarin.

But the guideline might already be outdated in not considering the results of the recent CRYSTAL-AF study, in which long-term cardiac rhythm monitoring of patients with a previous cryptogenic stroke detected asymptomatic patients at a significantly higher rate than did standard monitoring methods.

The guideline also extends the routine use of anticoagulation for patients with nonvalvular atrial fibrillation (NVAF) who are generally undertreated or whose health was thought a possible barrier to their use, such as those aged 75 years or older, those with mild dementia, and those at moderate risk of falls.

"Cognizant of the global reach of the AAN [American Academy of Neurology], the guideline also examines the evidence base for a treatment alternative to warfarin or its analogues for patients in developing countries who may not have access to the new oral anticoagulants," said lead author Dr. Antonio Culebras in an interview.

"The World Health Organization has determined that atrial fibrillation has reached near-epidemic proportions," observed Dr. Culebras of the State University of New York, Syracuse. "Approximately 1 in 20 individuals with AF will have a stroke unless treated appropriately."

The risk for stroke among patients with NVAF is highest in those with a history of transient ischemic attack (TIA) or prior stroke, at an absolute value of around 10% per year. Patients with "lone NVAF," meaning they have no additional risk factors, have less than a 2% increased risk of stroke per year.

The AAN issued a practice parameter on this topic in 1998 (Neurology 1998;51:671-3). At the time, warfarin, adjusted to an international normalized ratio (INR) of 2.0, was, and largely remains, the recommended standard for patients at risk for cardioembolic stroke. Aspirin was the only recommended alterative for those unable to receive the vitamin K antagonist or who were deemed to be at low risk of stroke, although the evidence was scanty.

Since then, several new oral anticoagulant agents have become available, including the direct thrombin inhibitor dabigatran (Pradaxa), and two factor Xa inhibitors – rivaroxaban (Xarelto) and apixaban (Eliquis) – which have been shown to be at least as effective as, if not more effective than, warfarin. Cardiac rhythm monitoring via a variety of methods has also been introduced as a means to try to detect NVAF in asymptomatic patients.

The aim of the AAN guideline (Neurology 2014;82:716-24) was therefore to look at the latest evidence on the detection of AF using new technologies, as well as the use of treatments to reduce the risk of stroke without increasing the risk of hemorrhage versus the long-standing standard of therapy, warfarin. Data published from 1998 to March 2013 were considered in the preparation of the guideline.

Cardiac rhythm monitoring for NVAF

Seventeen studies were found that examined the use of cardiac monitoring technologies to detect new cases of NVAF. The most common methods used were 24-hour Holter monitoring and serial electrocardiograms, but some emerging evidence on newer technologies was included. The proportion of patients identified with NVAF ranged from 0% to 23%, with the average detection rate 10.7% in all of the studies included.

"The guideline addresses the question of long-term monitoring of patients with NVAF," Dr. Culebras said. "It recommends that clinicians ‘might’ [level C evidence] obtain outpatient cardiac rhythm studies in patients with cryptogenic stroke without known NVAF to identify patients with occult NVAF." He added that the guideline also recommends that monitoring might be needed for prolonged periods of 1 or more weeks rather than for shorter periods, such as 24 hours.

However, at the time the guideline was being prepared, recent data from the CRYSTAL-AF study were not available, and this means the guideline is already outdated, Dr. Richard A. Bernstein, professor of neurology at Northwestern University, Chicago, said in an interview. He was not a guideline author.

Dr. Bernstein was on the steering committee for the CRYSTAL-AF trial, which assessed the performance of Medtronic’s Reveal XT Insertable Cardiac Monitor and found that the implanted device could detect NVAF better than serial ECGs or Holter monitoring (8.6% vs. 1.4%; P = .0006); most (74%) cases of NVAF found were asymptomatic.*

"CRYSTAL-AF represents the state of the art for cardiac monitoring in cryptogenic stroke patients and makes the AAN guidelines obsolete," Dr. Berstein said. "[The study] shows that even intermediate-term monitoring (less than 1 month) will miss the majority of AF in this population, and that most of the AF we find with long-term (greater than 1 year) monitoring is likely to be clinically significant."

With regard to the AAN guideline, he added: "There is no discussion of truly long-term monitoring in the guideline, which is unfortunate." That said, "anything that gets neurologists thinking about long-term cardiac monitoring is likely to be beneficial."

Anticoagulation for stroke prevention

The AAN guideline also provides general recommendations on the use of novel oral anticoagulant agents (NOACs) as alternatives to warfarin. Specifically, it notes that in comparison with warfarin, these NOACs are probably at least as effective (rivaroxaban) or more effective (dabigatran and apixaban). Additionally, while apixaban is also likely to be more effective than aspirin, it is associated with a similar risk for bleeding. NOACs have the following advantages over warfarin: an overall lower risk of intracranial hemorrhage and no need for routine anticoagulant monitoring.

From a practical perspective, the AAN guideline suggests that clinicians have the following options available: warfarin to reach an INR of 2.0-3.0, dabigatran 150 mg twice daily, rivaroxaban 15-20 mg/dL, apixaban 2.5-5 mg twice a day, and triflusal 600 mg plus acenocoumarol to reach an INR target of 1.25-2.0. If a patient is already taking warfarin and is well controlled, then they should remain on that therapy and not switch to a newer oral anticoagulant.

The guideline also notes that clopidogrel plus aspirin is probably less effective than warfarin, but the combination is probably better than aspirin alone. However, the risk of hemorrhage is higher.

Where used, triflusal plus acenocoumarol is "likely more effective" than acenocoumarol alone. Triflusal is an antiplatelet drug related to aspirin, used in Europe, Latin America, and Southeast Asia. Acenocoumarol is mostly used in European countries.

Dr. Culebras explained that the guideline was not intended to dictate which treatment to use. "The guideline leaves room on purpose for clinicians to use their judgment," he said. "The overall objective of the guideline is to reduce therapeutic uncertainty and not to issue commandments for treatment."

Although Dr. Bernstein was critical of the guidelines for not advocating the use of anticoagulants strongly enough, he said that the recommendations on anticoagulant choice are "reasonable in that they impute potential clinical profiles of patients who might particularly benefit from one NOAC over another, without making a claim that these recommendations are based on solid data. This reflects how doctors make decisions when we don’t have direct comparative studies, and I think that is helpful."

The guideline was developed with financial support from the American Academy of Neurology. None of the authors received reimbursement, honoraria, or stipends for their participation in the development of the guideline.

Dr. Culebras has received one-time funding for travel from J. Uriach & Co, and he serves on the editorial boards of MedLink, UpToDate.com, and the International Journal of Stroke. He has received royalties from Informa Healthcare and Cambridge University Press, and has held stock in Clinical Stroke Research. Other authors reported current or past ties to companies marketing oral anticoagulants and stroke treatments.

Dr. Bernstein was on the steering committee for the CRYSTAL-AF study and is a paid speaker, researcher, and consultant for Medtronic, Bristol-Myers Squibb, Pfizer, Boehringer Ingelheim, and Lifewatch.

*Correction, 4/8/2014: The article previously misstated what the implantable device was detecting in the CRYSTAL-AF study.

A new evidence-based guideline on how to identify and treat patients with nonvalvular atrial fibrillation to prevent cardioembolic stroke from the American Academy of Neurology suggests when to conduct cardiac rhythm monitoring and offer anticoagulation, including newer agents in place of warfarin.

But the guideline might already be outdated in not considering the results of the recent CRYSTAL-AF study, in which long-term cardiac rhythm monitoring of patients with a previous cryptogenic stroke detected asymptomatic patients at a significantly higher rate than did standard monitoring methods.

The guideline also extends the routine use of anticoagulation for patients with nonvalvular atrial fibrillation (NVAF) who are generally undertreated or whose health was thought a possible barrier to their use, such as those aged 75 years or older, those with mild dementia, and those at moderate risk of falls.

"Cognizant of the global reach of the AAN [American Academy of Neurology], the guideline also examines the evidence base for a treatment alternative to warfarin or its analogues for patients in developing countries who may not have access to the new oral anticoagulants," said lead author Dr. Antonio Culebras in an interview.

"The World Health Organization has determined that atrial fibrillation has reached near-epidemic proportions," observed Dr. Culebras of the State University of New York, Syracuse. "Approximately 1 in 20 individuals with AF will have a stroke unless treated appropriately."

The risk for stroke among patients with NVAF is highest in those with a history of transient ischemic attack (TIA) or prior stroke, at an absolute value of around 10% per year. Patients with "lone NVAF," meaning they have no additional risk factors, have less than a 2% increased risk of stroke per year.

The AAN issued a practice parameter on this topic in 1998 (Neurology 1998;51:671-3). At the time, warfarin, adjusted to an international normalized ratio (INR) of 2.0, was, and largely remains, the recommended standard for patients at risk for cardioembolic stroke. Aspirin was the only recommended alterative for those unable to receive the vitamin K antagonist or who were deemed to be at low risk of stroke, although the evidence was scanty.

Since then, several new oral anticoagulant agents have become available, including the direct thrombin inhibitor dabigatran (Pradaxa), and two factor Xa inhibitors – rivaroxaban (Xarelto) and apixaban (Eliquis) – which have been shown to be at least as effective as, if not more effective than, warfarin. Cardiac rhythm monitoring via a variety of methods has also been introduced as a means to try to detect NVAF in asymptomatic patients.

The aim of the AAN guideline (Neurology 2014;82:716-24) was therefore to look at the latest evidence on the detection of AF using new technologies, as well as the use of treatments to reduce the risk of stroke without increasing the risk of hemorrhage versus the long-standing standard of therapy, warfarin. Data published from 1998 to March 2013 were considered in the preparation of the guideline.

Cardiac rhythm monitoring for NVAF

Seventeen studies were found that examined the use of cardiac monitoring technologies to detect new cases of NVAF. The most common methods used were 24-hour Holter monitoring and serial electrocardiograms, but some emerging evidence on newer technologies was included. The proportion of patients identified with NVAF ranged from 0% to 23%, with the average detection rate 10.7% in all of the studies included.

"The guideline addresses the question of long-term monitoring of patients with NVAF," Dr. Culebras said. "It recommends that clinicians ‘might’ [level C evidence] obtain outpatient cardiac rhythm studies in patients with cryptogenic stroke without known NVAF to identify patients with occult NVAF." He added that the guideline also recommends that monitoring might be needed for prolonged periods of 1 or more weeks rather than for shorter periods, such as 24 hours.

However, at the time the guideline was being prepared, recent data from the CRYSTAL-AF study were not available, and this means the guideline is already outdated, Dr. Richard A. Bernstein, professor of neurology at Northwestern University, Chicago, said in an interview. He was not a guideline author.

Dr. Bernstein was on the steering committee for the CRYSTAL-AF trial, which assessed the performance of Medtronic’s Reveal XT Insertable Cardiac Monitor and found that the implanted device could detect NVAF better than serial ECGs or Holter monitoring (8.6% vs. 1.4%; P = .0006); most (74%) cases of NVAF found were asymptomatic.*

"CRYSTAL-AF represents the state of the art for cardiac monitoring in cryptogenic stroke patients and makes the AAN guidelines obsolete," Dr. Berstein said. "[The study] shows that even intermediate-term monitoring (less than 1 month) will miss the majority of AF in this population, and that most of the AF we find with long-term (greater than 1 year) monitoring is likely to be clinically significant."

With regard to the AAN guideline, he added: "There is no discussion of truly long-term monitoring in the guideline, which is unfortunate." That said, "anything that gets neurologists thinking about long-term cardiac monitoring is likely to be beneficial."

Anticoagulation for stroke prevention

The AAN guideline also provides general recommendations on the use of novel oral anticoagulant agents (NOACs) as alternatives to warfarin. Specifically, it notes that in comparison with warfarin, these NOACs are probably at least as effective (rivaroxaban) or more effective (dabigatran and apixaban). Additionally, while apixaban is also likely to be more effective than aspirin, it is associated with a similar risk for bleeding. NOACs have the following advantages over warfarin: an overall lower risk of intracranial hemorrhage and no need for routine anticoagulant monitoring.

From a practical perspective, the AAN guideline suggests that clinicians have the following options available: warfarin to reach an INR of 2.0-3.0, dabigatran 150 mg twice daily, rivaroxaban 15-20 mg/dL, apixaban 2.5-5 mg twice a day, and triflusal 600 mg plus acenocoumarol to reach an INR target of 1.25-2.0. If a patient is already taking warfarin and is well controlled, then they should remain on that therapy and not switch to a newer oral anticoagulant.

The guideline also notes that clopidogrel plus aspirin is probably less effective than warfarin, but the combination is probably better than aspirin alone. However, the risk of hemorrhage is higher.

Where used, triflusal plus acenocoumarol is "likely more effective" than acenocoumarol alone. Triflusal is an antiplatelet drug related to aspirin, used in Europe, Latin America, and Southeast Asia. Acenocoumarol is mostly used in European countries.

Dr. Culebras explained that the guideline was not intended to dictate which treatment to use. "The guideline leaves room on purpose for clinicians to use their judgment," he said. "The overall objective of the guideline is to reduce therapeutic uncertainty and not to issue commandments for treatment."

Although Dr. Bernstein was critical of the guidelines for not advocating the use of anticoagulants strongly enough, he said that the recommendations on anticoagulant choice are "reasonable in that they impute potential clinical profiles of patients who might particularly benefit from one NOAC over another, without making a claim that these recommendations are based on solid data. This reflects how doctors make decisions when we don’t have direct comparative studies, and I think that is helpful."

The guideline was developed with financial support from the American Academy of Neurology. None of the authors received reimbursement, honoraria, or stipends for their participation in the development of the guideline.

Dr. Culebras has received one-time funding for travel from J. Uriach & Co, and he serves on the editorial boards of MedLink, UpToDate.com, and the International Journal of Stroke. He has received royalties from Informa Healthcare and Cambridge University Press, and has held stock in Clinical Stroke Research. Other authors reported current or past ties to companies marketing oral anticoagulants and stroke treatments.

Dr. Bernstein was on the steering committee for the CRYSTAL-AF study and is a paid speaker, researcher, and consultant for Medtronic, Bristol-Myers Squibb, Pfizer, Boehringer Ingelheim, and Lifewatch.

*Correction, 4/8/2014: The article previously misstated what the implantable device was detecting in the CRYSTAL-AF study.

A new evidence-based guideline on how to identify and treat patients with nonvalvular atrial fibrillation to prevent cardioembolic stroke from the American Academy of Neurology suggests when to conduct cardiac rhythm monitoring and offer anticoagulation, including newer agents in place of warfarin.

But the guideline might already be outdated in not considering the results of the recent CRYSTAL-AF study, in which long-term cardiac rhythm monitoring of patients with a previous cryptogenic stroke detected asymptomatic patients at a significantly higher rate than did standard monitoring methods.

The guideline also extends the routine use of anticoagulation for patients with nonvalvular atrial fibrillation (NVAF) who are generally undertreated or whose health was thought a possible barrier to their use, such as those aged 75 years or older, those with mild dementia, and those at moderate risk of falls.

"Cognizant of the global reach of the AAN [American Academy of Neurology], the guideline also examines the evidence base for a treatment alternative to warfarin or its analogues for patients in developing countries who may not have access to the new oral anticoagulants," said lead author Dr. Antonio Culebras in an interview.

"The World Health Organization has determined that atrial fibrillation has reached near-epidemic proportions," observed Dr. Culebras of the State University of New York, Syracuse. "Approximately 1 in 20 individuals with AF will have a stroke unless treated appropriately."

The risk for stroke among patients with NVAF is highest in those with a history of transient ischemic attack (TIA) or prior stroke, at an absolute value of around 10% per year. Patients with "lone NVAF," meaning they have no additional risk factors, have less than a 2% increased risk of stroke per year.

The AAN issued a practice parameter on this topic in 1998 (Neurology 1998;51:671-3). At the time, warfarin, adjusted to an international normalized ratio (INR) of 2.0, was, and largely remains, the recommended standard for patients at risk for cardioembolic stroke. Aspirin was the only recommended alterative for those unable to receive the vitamin K antagonist or who were deemed to be at low risk of stroke, although the evidence was scanty.

Since then, several new oral anticoagulant agents have become available, including the direct thrombin inhibitor dabigatran (Pradaxa), and two factor Xa inhibitors – rivaroxaban (Xarelto) and apixaban (Eliquis) – which have been shown to be at least as effective as, if not more effective than, warfarin. Cardiac rhythm monitoring via a variety of methods has also been introduced as a means to try to detect NVAF in asymptomatic patients.

The aim of the AAN guideline (Neurology 2014;82:716-24) was therefore to look at the latest evidence on the detection of AF using new technologies, as well as the use of treatments to reduce the risk of stroke without increasing the risk of hemorrhage versus the long-standing standard of therapy, warfarin. Data published from 1998 to March 2013 were considered in the preparation of the guideline.

Cardiac rhythm monitoring for NVAF

Seventeen studies were found that examined the use of cardiac monitoring technologies to detect new cases of NVAF. The most common methods used were 24-hour Holter monitoring and serial electrocardiograms, but some emerging evidence on newer technologies was included. The proportion of patients identified with NVAF ranged from 0% to 23%, with the average detection rate 10.7% in all of the studies included.

"The guideline addresses the question of long-term monitoring of patients with NVAF," Dr. Culebras said. "It recommends that clinicians ‘might’ [level C evidence] obtain outpatient cardiac rhythm studies in patients with cryptogenic stroke without known NVAF to identify patients with occult NVAF." He added that the guideline also recommends that monitoring might be needed for prolonged periods of 1 or more weeks rather than for shorter periods, such as 24 hours.

However, at the time the guideline was being prepared, recent data from the CRYSTAL-AF study were not available, and this means the guideline is already outdated, Dr. Richard A. Bernstein, professor of neurology at Northwestern University, Chicago, said in an interview. He was not a guideline author.

Dr. Bernstein was on the steering committee for the CRYSTAL-AF trial, which assessed the performance of Medtronic’s Reveal XT Insertable Cardiac Monitor and found that the implanted device could detect NVAF better than serial ECGs or Holter monitoring (8.6% vs. 1.4%; P = .0006); most (74%) cases of NVAF found were asymptomatic.*

"CRYSTAL-AF represents the state of the art for cardiac monitoring in cryptogenic stroke patients and makes the AAN guidelines obsolete," Dr. Berstein said. "[The study] shows that even intermediate-term monitoring (less than 1 month) will miss the majority of AF in this population, and that most of the AF we find with long-term (greater than 1 year) monitoring is likely to be clinically significant."

With regard to the AAN guideline, he added: "There is no discussion of truly long-term monitoring in the guideline, which is unfortunate." That said, "anything that gets neurologists thinking about long-term cardiac monitoring is likely to be beneficial."

Anticoagulation for stroke prevention

The AAN guideline also provides general recommendations on the use of novel oral anticoagulant agents (NOACs) as alternatives to warfarin. Specifically, it notes that in comparison with warfarin, these NOACs are probably at least as effective (rivaroxaban) or more effective (dabigatran and apixaban). Additionally, while apixaban is also likely to be more effective than aspirin, it is associated with a similar risk for bleeding. NOACs have the following advantages over warfarin: an overall lower risk of intracranial hemorrhage and no need for routine anticoagulant monitoring.

From a practical perspective, the AAN guideline suggests that clinicians have the following options available: warfarin to reach an INR of 2.0-3.0, dabigatran 150 mg twice daily, rivaroxaban 15-20 mg/dL, apixaban 2.5-5 mg twice a day, and triflusal 600 mg plus acenocoumarol to reach an INR target of 1.25-2.0. If a patient is already taking warfarin and is well controlled, then they should remain on that therapy and not switch to a newer oral anticoagulant.

The guideline also notes that clopidogrel plus aspirin is probably less effective than warfarin, but the combination is probably better than aspirin alone. However, the risk of hemorrhage is higher.

Where used, triflusal plus acenocoumarol is "likely more effective" than acenocoumarol alone. Triflusal is an antiplatelet drug related to aspirin, used in Europe, Latin America, and Southeast Asia. Acenocoumarol is mostly used in European countries.

Dr. Culebras explained that the guideline was not intended to dictate which treatment to use. "The guideline leaves room on purpose for clinicians to use their judgment," he said. "The overall objective of the guideline is to reduce therapeutic uncertainty and not to issue commandments for treatment."

Although Dr. Bernstein was critical of the guidelines for not advocating the use of anticoagulants strongly enough, he said that the recommendations on anticoagulant choice are "reasonable in that they impute potential clinical profiles of patients who might particularly benefit from one NOAC over another, without making a claim that these recommendations are based on solid data. This reflects how doctors make decisions when we don’t have direct comparative studies, and I think that is helpful."

The guideline was developed with financial support from the American Academy of Neurology. None of the authors received reimbursement, honoraria, or stipends for their participation in the development of the guideline.

Dr. Culebras has received one-time funding for travel from J. Uriach & Co, and he serves on the editorial boards of MedLink, UpToDate.com, and the International Journal of Stroke. He has received royalties from Informa Healthcare and Cambridge University Press, and has held stock in Clinical Stroke Research. Other authors reported current or past ties to companies marketing oral anticoagulants and stroke treatments.

Dr. Bernstein was on the steering committee for the CRYSTAL-AF study and is a paid speaker, researcher, and consultant for Medtronic, Bristol-Myers Squibb, Pfizer, Boehringer Ingelheim, and Lifewatch.

*Correction, 4/8/2014: The article previously misstated what the implantable device was detecting in the CRYSTAL-AF study.

SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.

Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.

What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.

In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.

A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.

One-step vs. two-step approach

"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.

The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.

On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.

"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."

During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.

Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.

"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."

In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.

"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "

In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.

The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.

Individualized diabetes care

"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.

To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.

Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.

"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.

Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.

Other revisions include:

• Clarification that the hemoglobin A_1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;

• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;

• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and

• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.

"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.

The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.

ADA dodges dietary dogma

Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:

• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.

• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.

• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.

• Early referral to registered dietitians and nutritionists for nutrition therapy.

• First-ever call to avoid sugar-sweetened beverages.

• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.

• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.

Dr. Grant disclosed no conflicts of interest.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.

Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.

What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.

In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.

A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.

One-step vs. two-step approach

"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.

The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.

On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.

"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."

During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.

Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.

"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."

In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.

"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "

In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.

The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.

Individualized diabetes care

"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.

To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.

Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.

"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.

Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.

Other revisions include:

• Clarification that the hemoglobin A_1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;

• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;

• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and

• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.

"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.

The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.

ADA dodges dietary dogma

Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:

• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.

• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.

• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.

• Early referral to registered dietitians and nutritionists for nutrition therapy.

• First-ever call to avoid sugar-sweetened beverages.

• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.

• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.

Dr. Grant disclosed no conflicts of interest.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.

Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.

What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.

In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.

A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.

One-step vs. two-step approach

"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.

The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.

On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.

"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."

During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.

Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.

"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."

In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.

"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "

In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.

The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.

Individualized diabetes care

"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.

To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.

Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.

"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.

Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.

Other revisions include:

• Clarification that the hemoglobin A_1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;

• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;

• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and

• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.

"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.

The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.

ADA dodges dietary dogma

Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:

• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.

• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.

• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.

• Early referral to registered dietitians and nutritionists for nutrition therapy.

• First-ever call to avoid sugar-sweetened beverages.

• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.

• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.

Dr. Grant disclosed no conflicts of interest.

pwendling@frontlinemedcom.com

Newly released guidelines provide the first evidence-based recommendations for preventing stroke in women.

The document addresses the issues that uniquely increase stroke risk in women – pregnancy, hormonal therapy, contraception, and migraine – along with factors like atrial fibrillation and obesity, Dr. Cheryl Bushnell and her colleagues wrote in the February issue of Stroke.

"If you are a woman, you share many of the same risk factors for stroke with men, but your risk is also influenced by hormones, reproductive health, pregnancy, childbirth, and other sex-related factors," Dr. Bushnell noted in a press statement.

The document – created by the American Heart Association and American Stroke Association – is the first to look at these gender-specific issues, wrote Dr. Bushnell, director of the Stroke Center at Wake Forest Baptist Medical Center in Winston-Salem, N.C. (Stroke 2014 [doi:10.1161/01.str.0000442009.06663.48]).

It provides graded evidence for preventive strategies in a number of risk categories. Evidence was obtained by examining dozens of studies numbering hundreds of thousands of women. But despite the extant literature, Dr. Bushnell and her colleagues said more research needs to be conducted.

©moodboard/thinkstockphotos.com

"There is a need for recognition of women’s unique, sex-specific stroke risk factors, and a risk score that includes these factors would thereby identify women at risk," they wrote. "Similarly, it is important to improve stroke awareness and provide more rigorous education to women at younger ages, including childbearing ages."

The guidelines are aimed at primary care providers, who have the biggest interface with women at a prevention level – and intended to help them forge an active partnership with patients.

"More importantly," the authors wrote, "this guideline may empower women and their families to understand their own risk and how they can minimize the chances of having a stroke."

Pregnancy

For recommendations on pregnancy outcomes and stroke related to preeclampsia, the guidelines drew on evidence from 17 studies.

For women with chronic primary or secondary hypertension, or with a history of pregnancy-related hypertension, Level A evidence supports using low-dose aspirin during the second and third trimester. Level A evidence also supports calcium supplementation to prevent preeclampsia in women with low dietary intake.

There was also a Level A recommendation to treat severe hypertension during pregnancy with safe antihypertensives (methyldopa, labetalol, and nifedipine). Level B evidence supported treating moderate hypertension. The use of atenolol, angiotensin receptor blockers, and direct renin inhibitors is contraindicated because of teratogenicity.

Because preeclampsia increases lifelong stroke risk, the guidelines also recommended evaluating these women within 1 year of giving birth, and, based on their individual and family risk factors, possibly treating them for cardiovascular risk factors.

Oral contraceptives

Four studies comprising about 800,000 women examined the risk of stroke in women using hormonal birth control.

Level A evidence did not support routine screening for prothrombotic mutations before starting oral contraception. But there was Level B evidence that oral contraceptives may be harmful in women who had risk factors, including cigarette use and prior thromboembolic events.

Menopause-related hormone therapy

Seven studies – including the Women’s Health Initiative – examined the links between stroke and hormone therapy in about 37,000 women. Two recommendations supported by Level A evidence were made.

Hormone therapy should not be used for either primary or secondary stroke prevention in postmenopausal women.

Selective estrogen receptor modulators (raloxifene, tamoxifen, and tibolone) should not be used for primary prevention of stroke.

Migraine with aura

There is scant literature examining the link between migraine with aura and stroke, although what does exist suggests that the risk may be doubled overall. The addition of another factor, like pregnancy or preeclampsia, dramatically increases the risk. But because these data are low in number, the recommendations are the same as they are for men.

Level B evidence supports smoking cessation in women with migraine and aura. Level C evidence suggests that treatments that reduce the frequency of migraine may also reduce the risk of stroke.

Obesity and metabolic syndrome

A healthy lifestyle of eating whole foods, exercise, and abstaining from tobacco has been shown to lower stroke incidence in both women and men. But subgroup analyses hint that men derive the most benefit. Women-only studies of these interventions have posted mixed results about their ability to reduce stroke in women.

The authors said much more research is necessary to target interventions that are especially beneficial for women. Until then, Level B evidence supports maintaining a lifestyle of exercise, healthy eating, no tobacco use, and moderate alcohol intake (a drink a day or less) for women who aren’t pregnant.

Atrial fibrillation

Overall, similar numbers of women and men have atrial fibrillation. But the condition becomes more common with age, and women have a longer life expectancy than do men. Therefore, the authors noted, atrial fibrillation will become more common as the population of elderly women increases.

They recommend that primary care physicians actively screen women for atrial fibrillation once they reach age 75 years. The screening method, supported by Level B evidence, should be pulse followed by an electrocardiogram.

For women aged 65 years and younger who have atrial fibrillation but no other risk factors, there is no evidence supporting oral anticoagulation. Level B evidence does support antiplatelet therapy.

Dr. Bushnell had no financial disclosures. One of the 16 coauthors reported relationships with several pharmaceutical companies

msullivan@frontlinemedcom.com

On Twitter @alz_gal

Newly released guidelines provide the first evidence-based recommendations for preventing stroke in women.

The document addresses the issues that uniquely increase stroke risk in women – pregnancy, hormonal therapy, contraception, and migraine – along with factors like atrial fibrillation and obesity, Dr. Cheryl Bushnell and her colleagues wrote in the February issue of Stroke.

"If you are a woman, you share many of the same risk factors for stroke with men, but your risk is also influenced by hormones, reproductive health, pregnancy, childbirth, and other sex-related factors," Dr. Bushnell noted in a press statement.

The document – created by the American Heart Association and American Stroke Association – is the first to look at these gender-specific issues, wrote Dr. Bushnell, director of the Stroke Center at Wake Forest Baptist Medical Center in Winston-Salem, N.C. (Stroke 2014 [doi:10.1161/01.str.0000442009.06663.48]).

It provides graded evidence for preventive strategies in a number of risk categories. Evidence was obtained by examining dozens of studies numbering hundreds of thousands of women. But despite the extant literature, Dr. Bushnell and her colleagues said more research needs to be conducted.

©moodboard/thinkstockphotos.com

"There is a need for recognition of women’s unique, sex-specific stroke risk factors, and a risk score that includes these factors would thereby identify women at risk," they wrote. "Similarly, it is important to improve stroke awareness and provide more rigorous education to women at younger ages, including childbearing ages."

The guidelines are aimed at primary care providers, who have the biggest interface with women at a prevention level – and intended to help them forge an active partnership with patients.

"More importantly," the authors wrote, "this guideline may empower women and their families to understand their own risk and how they can minimize the chances of having a stroke."

Pregnancy

For recommendations on pregnancy outcomes and stroke related to preeclampsia, the guidelines drew on evidence from 17 studies.

For women with chronic primary or secondary hypertension, or with a history of pregnancy-related hypertension, Level A evidence supports using low-dose aspirin during the second and third trimester. Level A evidence also supports calcium supplementation to prevent preeclampsia in women with low dietary intake.

There was also a Level A recommendation to treat severe hypertension during pregnancy with safe antihypertensives (methyldopa, labetalol, and nifedipine). Level B evidence supported treating moderate hypertension. The use of atenolol, angiotensin receptor blockers, and direct renin inhibitors is contraindicated because of teratogenicity.

Because preeclampsia increases lifelong stroke risk, the guidelines also recommended evaluating these women within 1 year of giving birth, and, based on their individual and family risk factors, possibly treating them for cardiovascular risk factors.

Oral contraceptives

Four studies comprising about 800,000 women examined the risk of stroke in women using hormonal birth control.

Level A evidence did not support routine screening for prothrombotic mutations before starting oral contraception. But there was Level B evidence that oral contraceptives may be harmful in women who had risk factors, including cigarette use and prior thromboembolic events.

Menopause-related hormone therapy

Seven studies – including the Women’s Health Initiative – examined the links between stroke and hormone therapy in about 37,000 women. Two recommendations supported by Level A evidence were made.

Hormone therapy should not be used for either primary or secondary stroke prevention in postmenopausal women.

Selective estrogen receptor modulators (raloxifene, tamoxifen, and tibolone) should not be used for primary prevention of stroke.

Migraine with aura

There is scant literature examining the link between migraine with aura and stroke, although what does exist suggests that the risk may be doubled overall. The addition of another factor, like pregnancy or preeclampsia, dramatically increases the risk. But because these data are low in number, the recommendations are the same as they are for men.

Level B evidence supports smoking cessation in women with migraine and aura. Level C evidence suggests that treatments that reduce the frequency of migraine may also reduce the risk of stroke.

Obesity and metabolic syndrome

A healthy lifestyle of eating whole foods, exercise, and abstaining from tobacco has been shown to lower stroke incidence in both women and men. But subgroup analyses hint that men derive the most benefit. Women-only studies of these interventions have posted mixed results about their ability to reduce stroke in women.

The authors said much more research is necessary to target interventions that are especially beneficial for women. Until then, Level B evidence supports maintaining a lifestyle of exercise, healthy eating, no tobacco use, and moderate alcohol intake (a drink a day or less) for women who aren’t pregnant.

Atrial fibrillation

Overall, similar numbers of women and men have atrial fibrillation. But the condition becomes more common with age, and women have a longer life expectancy than do men. Therefore, the authors noted, atrial fibrillation will become more common as the population of elderly women increases.

They recommend that primary care physicians actively screen women for atrial fibrillation once they reach age 75 years. The screening method, supported by Level B evidence, should be pulse followed by an electrocardiogram.

For women aged 65 years and younger who have atrial fibrillation but no other risk factors, there is no evidence supporting oral anticoagulation. Level B evidence does support antiplatelet therapy.

Dr. Bushnell had no financial disclosures. One of the 16 coauthors reported relationships with several pharmaceutical companies

msullivan@frontlinemedcom.com

On Twitter @alz_gal

Newly released guidelines provide the first evidence-based recommendations for preventing stroke in women.

The document addresses the issues that uniquely increase stroke risk in women – pregnancy, hormonal therapy, contraception, and migraine – along with factors like atrial fibrillation and obesity, Dr. Cheryl Bushnell and her colleagues wrote in the February issue of Stroke.

"If you are a woman, you share many of the same risk factors for stroke with men, but your risk is also influenced by hormones, reproductive health, pregnancy, childbirth, and other sex-related factors," Dr. Bushnell noted in a press statement.

The document – created by the American Heart Association and American Stroke Association – is the first to look at these gender-specific issues, wrote Dr. Bushnell, director of the Stroke Center at Wake Forest Baptist Medical Center in Winston-Salem, N.C. (Stroke 2014 [doi:10.1161/01.str.0000442009.06663.48]).

It provides graded evidence for preventive strategies in a number of risk categories. Evidence was obtained by examining dozens of studies numbering hundreds of thousands of women. But despite the extant literature, Dr. Bushnell and her colleagues said more research needs to be conducted.

©moodboard/thinkstockphotos.com

"There is a need for recognition of women’s unique, sex-specific stroke risk factors, and a risk score that includes these factors would thereby identify women at risk," they wrote. "Similarly, it is important to improve stroke awareness and provide more rigorous education to women at younger ages, including childbearing ages."

The guidelines are aimed at primary care providers, who have the biggest interface with women at a prevention level – and intended to help them forge an active partnership with patients.

"More importantly," the authors wrote, "this guideline may empower women and their families to understand their own risk and how they can minimize the chances of having a stroke."

Pregnancy

For recommendations on pregnancy outcomes and stroke related to preeclampsia, the guidelines drew on evidence from 17 studies.

For women with chronic primary or secondary hypertension, or with a history of pregnancy-related hypertension, Level A evidence supports using low-dose aspirin during the second and third trimester. Level A evidence also supports calcium supplementation to prevent preeclampsia in women with low dietary intake.

There was also a Level A recommendation to treat severe hypertension during pregnancy with safe antihypertensives (methyldopa, labetalol, and nifedipine). Level B evidence supported treating moderate hypertension. The use of atenolol, angiotensin receptor blockers, and direct renin inhibitors is contraindicated because of teratogenicity.

Because preeclampsia increases lifelong stroke risk, the guidelines also recommended evaluating these women within 1 year of giving birth, and, based on their individual and family risk factors, possibly treating them for cardiovascular risk factors.

Oral contraceptives

Four studies comprising about 800,000 women examined the risk of stroke in women using hormonal birth control.

Level A evidence did not support routine screening for prothrombotic mutations before starting oral contraception. But there was Level B evidence that oral contraceptives may be harmful in women who had risk factors, including cigarette use and prior thromboembolic events.

Menopause-related hormone therapy

Seven studies – including the Women’s Health Initiative – examined the links between stroke and hormone therapy in about 37,000 women. Two recommendations supported by Level A evidence were made.

Hormone therapy should not be used for either primary or secondary stroke prevention in postmenopausal women.

Selective estrogen receptor modulators (raloxifene, tamoxifen, and tibolone) should not be used for primary prevention of stroke.

Migraine with aura

There is scant literature examining the link between migraine with aura and stroke, although what does exist suggests that the risk may be doubled overall. The addition of another factor, like pregnancy or preeclampsia, dramatically increases the risk. But because these data are low in number, the recommendations are the same as they are for men.

Level B evidence supports smoking cessation in women with migraine and aura. Level C evidence suggests that treatments that reduce the frequency of migraine may also reduce the risk of stroke.

Obesity and metabolic syndrome

A healthy lifestyle of eating whole foods, exercise, and abstaining from tobacco has been shown to lower stroke incidence in both women and men. But subgroup analyses hint that men derive the most benefit. Women-only studies of these interventions have posted mixed results about their ability to reduce stroke in women.

The authors said much more research is necessary to target interventions that are especially beneficial for women. Until then, Level B evidence supports maintaining a lifestyle of exercise, healthy eating, no tobacco use, and moderate alcohol intake (a drink a day or less) for women who aren’t pregnant.

Atrial fibrillation

Overall, similar numbers of women and men have atrial fibrillation. But the condition becomes more common with age, and women have a longer life expectancy than do men. Therefore, the authors noted, atrial fibrillation will become more common as the population of elderly women increases.

They recommend that primary care physicians actively screen women for atrial fibrillation once they reach age 75 years. The screening method, supported by Level B evidence, should be pulse followed by an electrocardiogram.

For women aged 65 years and younger who have atrial fibrillation but no other risk factors, there is no evidence supporting oral anticoagulation. Level B evidence does support antiplatelet therapy.

Dr. Bushnell had no financial disclosures. One of the 16 coauthors reported relationships with several pharmaceutical companies

msullivan@frontlinemedcom.com

On Twitter @alz_gal

The U.S. Preventive Services Task Force has released updated recommendations regarding screening for intimate partner violence and abuse of elderly and vulnerable adults. While their previous recommendations in 2004 gave intimate partner violence screening an "I" recommendation, meaning that the evidence was inconclusive regarding the balance of benefits and intimate partner violence harms, the current recommendation has been upgraded to a "B" recommendation, meaning there is moderate certainty that there is a net benefit from screening. This puts the USPSTF recommendation in alignment with those of most other groups, including the American Medical Association and the *American College of Obstetricians and Gynecologists.

Forms of abuse

The recommendations regarding intimate partner violence in these guidelines refer to physical, sexual, or psychological abuse of women of reproductive age by a current or former partner or spouse. The issue of intimate partner violence is important because research shows that approximately 31% of women and 26% of men have experienced intimate partner violence within their lifetime, and that intimate partner violence is usually undetected. It is also estimated that these numbers are likely to be low because of underreporting. In one large study, the 1-year incidence of abuse was 8% within the last year and 15% within the last 5 years. Approximately 1.5%-5% of pregnant women report being abused. Among older and vulnerable adults, the rate of physical, psychological, or sexual abuse; neglect; or financial exploitation is estimated to be between 2% and 10%.

Intimate partner violence has important and long-lasting effects on victims. Harmful effects include immediate injuries resulting from direct trauma as well as long-term physical and mental health consequences. Long-term physical consequences include sexually transmitted diseases, unintended pregnancy, and worse pregnancy outcomes, as well as higher rates of chronic pain, gastrointestinal disorders, migraine headaches, and disability. Long-term mental health consequences include depression, post-traumatic stress disorder, anxiety disorders, substance abuse, and a higher rate of suicide.

Screening of women

Intimate partner violence in women can be detected with a high level of certainty. There are specific factors that can influence the chances that an individual is at risk for intimate partner violence and can alert clinicians to have increased vigilance for abuse. These risk factors have four categories. The first category is individual, focusing on an individual’s self-esteem. The second is relationship, which focuses on marriage conflict and stability within relationships. Third is community, which is looking at socioeconomic background. Fourth are the societal factors of traditional gender roles.

Many screening instruments exist that have been carefully studied. For instance, the HITS instrument, available in English and Spanish, is a four-item questionnaire that asks about being hurt, insulted, screamed at, or threatened. In one study, it had a sensitivity of 86% and a specificity of 99% for detecting intimate partner violence. The interval for screening is not clear.

Treatment

Once intimate partner violence among women is detected, many approaches are available to help these women. For example, one trial was set up to test the effectiveness of a mentoring support group vs. usual care. All women who entered this trial had discussed intimate partner violence with their primary care physician. After the intervention program, the women who were in the intervention group had significantly reduced scores of abuse as opposed to the comparison group. Another example is a study of pregnant women who reported abuse, who were then randomized to a counseling intervention vs. usual care. Women in the counseling group had decreased pregnancy coercion and were more likely to discontinue an unhealthy or unsafe relationship.

Approaches vary from counseling to social work interventions brought to peoples’ homes, information cards, referral to community services, and mentoring support services. It appears that varied interventions decrease recurrent abuse. There is no reported harm in screening for intimate partner violence. It is necessary for the primary care doctor to be aware of the laws specific to intimate partner violence reporting and privacy within the doctor’s specific region.

Elderly and vulnerable adults

In contrast to screening for intimate partner violence in women, there is a lack of evidence for abuse screening in elderly and vulnerable adult populations. There is a lack of evidence on the benefits of detection and, surprisingly, a lack of evidence on the benefits of early intervention. It is also possible that the harms of detecting abuse in this group may be different, although the risk appears to be small. Some potential harm includes shame, guilt, fear of retaliation, and abandonment by caretakers who have been accused of abuse.

While the evidence to support screening elderly and vulnerable adults is limited, state and local laws vary about the obligation and logistics of reporting elderly abuse. A main conclusion of the USPSTF is that more evidence-based research needs to be done for the population of elderly and vulnerable adults.

Bottom line

Intimate partner violence is common, affecting a quarter of all adults at some point in their life. The mental and physical effects of intimate partner violence can be severe and long-lasting. Screening for intimate partner violence is effective, and effective interventions can be carried out to help women who are victims of intimate partner violence. The USPSTF recommends routine screening of women of reproductive age for intimate partner violence. The data on screening for abuse in the elderly and vulnerable adults is insufficient for the USPSTF to make a recommendation for or against screening.

Reference

• Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: U.S. Preventive Services Task Force Recommendation Statement. (Ann. Intern. Med. 2013:158;478-86).

Ms. Skolnik attends Drexel University, Philadelphia, and is a research assistant at the Children’s Hospital of Pennsylvania. Dr. Clouse is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital.

*Correction 1/23/14: A previous version of this article misstated the name of the American College of Obstetricians and Gynecologists. This version has been updated. 

The U.S. Preventive Services Task Force has released updated recommendations regarding screening for intimate partner violence and abuse of elderly and vulnerable adults. While their previous recommendations in 2004 gave intimate partner violence screening an "I" recommendation, meaning that the evidence was inconclusive regarding the balance of benefits and intimate partner violence harms, the current recommendation has been upgraded to a "B" recommendation, meaning there is moderate certainty that there is a net benefit from screening. This puts the USPSTF recommendation in alignment with those of most other groups, including the American Medical Association and the *American College of Obstetricians and Gynecologists.

Forms of abuse

The recommendations regarding intimate partner violence in these guidelines refer to physical, sexual, or psychological abuse of women of reproductive age by a current or former partner or spouse. The issue of intimate partner violence is important because research shows that approximately 31% of women and 26% of men have experienced intimate partner violence within their lifetime, and that intimate partner violence is usually undetected. It is also estimated that these numbers are likely to be low because of underreporting. In one large study, the 1-year incidence of abuse was 8% within the last year and 15% within the last 5 years. Approximately 1.5%-5% of pregnant women report being abused. Among older and vulnerable adults, the rate of physical, psychological, or sexual abuse; neglect; or financial exploitation is estimated to be between 2% and 10%.

Intimate partner violence has important and long-lasting effects on victims. Harmful effects include immediate injuries resulting from direct trauma as well as long-term physical and mental health consequences. Long-term physical consequences include sexually transmitted diseases, unintended pregnancy, and worse pregnancy outcomes, as well as higher rates of chronic pain, gastrointestinal disorders, migraine headaches, and disability. Long-term mental health consequences include depression, post-traumatic stress disorder, anxiety disorders, substance abuse, and a higher rate of suicide.

Screening of women

Intimate partner violence in women can be detected with a high level of certainty. There are specific factors that can influence the chances that an individual is at risk for intimate partner violence and can alert clinicians to have increased vigilance for abuse. These risk factors have four categories. The first category is individual, focusing on an individual’s self-esteem. The second is relationship, which focuses on marriage conflict and stability within relationships. Third is community, which is looking at socioeconomic background. Fourth are the societal factors of traditional gender roles.

Many screening instruments exist that have been carefully studied. For instance, the HITS instrument, available in English and Spanish, is a four-item questionnaire that asks about being hurt, insulted, screamed at, or threatened. In one study, it had a sensitivity of 86% and a specificity of 99% for detecting intimate partner violence. The interval for screening is not clear.

Treatment

Once intimate partner violence among women is detected, many approaches are available to help these women. For example, one trial was set up to test the effectiveness of a mentoring support group vs. usual care. All women who entered this trial had discussed intimate partner violence with their primary care physician. After the intervention program, the women who were in the intervention group had significantly reduced scores of abuse as opposed to the comparison group. Another example is a study of pregnant women who reported abuse, who were then randomized to a counseling intervention vs. usual care. Women in the counseling group had decreased pregnancy coercion and were more likely to discontinue an unhealthy or unsafe relationship.

Approaches vary from counseling to social work interventions brought to peoples’ homes, information cards, referral to community services, and mentoring support services. It appears that varied interventions decrease recurrent abuse. There is no reported harm in screening for intimate partner violence. It is necessary for the primary care doctor to be aware of the laws specific to intimate partner violence reporting and privacy within the doctor’s specific region.

Elderly and vulnerable adults

In contrast to screening for intimate partner violence in women, there is a lack of evidence for abuse screening in elderly and vulnerable adult populations. There is a lack of evidence on the benefits of detection and, surprisingly, a lack of evidence on the benefits of early intervention. It is also possible that the harms of detecting abuse in this group may be different, although the risk appears to be small. Some potential harm includes shame, guilt, fear of retaliation, and abandonment by caretakers who have been accused of abuse.

While the evidence to support screening elderly and vulnerable adults is limited, state and local laws vary about the obligation and logistics of reporting elderly abuse. A main conclusion of the USPSTF is that more evidence-based research needs to be done for the population of elderly and vulnerable adults.

Bottom line

Intimate partner violence is common, affecting a quarter of all adults at some point in their life. The mental and physical effects of intimate partner violence can be severe and long-lasting. Screening for intimate partner violence is effective, and effective interventions can be carried out to help women who are victims of intimate partner violence. The USPSTF recommends routine screening of women of reproductive age for intimate partner violence. The data on screening for abuse in the elderly and vulnerable adults is insufficient for the USPSTF to make a recommendation for or against screening.

Reference

• Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: U.S. Preventive Services Task Force Recommendation Statement. (Ann. Intern. Med. 2013:158;478-86).

Ms. Skolnik attends Drexel University, Philadelphia, and is a research assistant at the Children’s Hospital of Pennsylvania. Dr. Clouse is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital.

*Correction 1/23/14: A previous version of this article misstated the name of the American College of Obstetricians and Gynecologists. This version has been updated. 

The U.S. Preventive Services Task Force has released updated recommendations regarding screening for intimate partner violence and abuse of elderly and vulnerable adults. While their previous recommendations in 2004 gave intimate partner violence screening an "I" recommendation, meaning that the evidence was inconclusive regarding the balance of benefits and intimate partner violence harms, the current recommendation has been upgraded to a "B" recommendation, meaning there is moderate certainty that there is a net benefit from screening. This puts the USPSTF recommendation in alignment with those of most other groups, including the American Medical Association and the *American College of Obstetricians and Gynecologists.

Forms of abuse

The recommendations regarding intimate partner violence in these guidelines refer to physical, sexual, or psychological abuse of women of reproductive age by a current or former partner or spouse. The issue of intimate partner violence is important because research shows that approximately 31% of women and 26% of men have experienced intimate partner violence within their lifetime, and that intimate partner violence is usually undetected. It is also estimated that these numbers are likely to be low because of underreporting. In one large study, the 1-year incidence of abuse was 8% within the last year and 15% within the last 5 years. Approximately 1.5%-5% of pregnant women report being abused. Among older and vulnerable adults, the rate of physical, psychological, or sexual abuse; neglect; or financial exploitation is estimated to be between 2% and 10%.

Intimate partner violence has important and long-lasting effects on victims. Harmful effects include immediate injuries resulting from direct trauma as well as long-term physical and mental health consequences. Long-term physical consequences include sexually transmitted diseases, unintended pregnancy, and worse pregnancy outcomes, as well as higher rates of chronic pain, gastrointestinal disorders, migraine headaches, and disability. Long-term mental health consequences include depression, post-traumatic stress disorder, anxiety disorders, substance abuse, and a higher rate of suicide.

Screening of women

Intimate partner violence in women can be detected with a high level of certainty. There are specific factors that can influence the chances that an individual is at risk for intimate partner violence and can alert clinicians to have increased vigilance for abuse. These risk factors have four categories. The first category is individual, focusing on an individual’s self-esteem. The second is relationship, which focuses on marriage conflict and stability within relationships. Third is community, which is looking at socioeconomic background. Fourth are the societal factors of traditional gender roles.

Many screening instruments exist that have been carefully studied. For instance, the HITS instrument, available in English and Spanish, is a four-item questionnaire that asks about being hurt, insulted, screamed at, or threatened. In one study, it had a sensitivity of 86% and a specificity of 99% for detecting intimate partner violence. The interval for screening is not clear.

Treatment

Once intimate partner violence among women is detected, many approaches are available to help these women. For example, one trial was set up to test the effectiveness of a mentoring support group vs. usual care. All women who entered this trial had discussed intimate partner violence with their primary care physician. After the intervention program, the women who were in the intervention group had significantly reduced scores of abuse as opposed to the comparison group. Another example is a study of pregnant women who reported abuse, who were then randomized to a counseling intervention vs. usual care. Women in the counseling group had decreased pregnancy coercion and were more likely to discontinue an unhealthy or unsafe relationship.

Approaches vary from counseling to social work interventions brought to peoples’ homes, information cards, referral to community services, and mentoring support services. It appears that varied interventions decrease recurrent abuse. There is no reported harm in screening for intimate partner violence. It is necessary for the primary care doctor to be aware of the laws specific to intimate partner violence reporting and privacy within the doctor’s specific region.

Elderly and vulnerable adults

In contrast to screening for intimate partner violence in women, there is a lack of evidence for abuse screening in elderly and vulnerable adult populations. There is a lack of evidence on the benefits of detection and, surprisingly, a lack of evidence on the benefits of early intervention. It is also possible that the harms of detecting abuse in this group may be different, although the risk appears to be small. Some potential harm includes shame, guilt, fear of retaliation, and abandonment by caretakers who have been accused of abuse.

While the evidence to support screening elderly and vulnerable adults is limited, state and local laws vary about the obligation and logistics of reporting elderly abuse. A main conclusion of the USPSTF is that more evidence-based research needs to be done for the population of elderly and vulnerable adults.

Bottom line

Intimate partner violence is common, affecting a quarter of all adults at some point in their life. The mental and physical effects of intimate partner violence can be severe and long-lasting. Screening for intimate partner violence is effective, and effective interventions can be carried out to help women who are victims of intimate partner violence. The USPSTF recommends routine screening of women of reproductive age for intimate partner violence. The data on screening for abuse in the elderly and vulnerable adults is insufficient for the USPSTF to make a recommendation for or against screening.

Reference

• Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: U.S. Preventive Services Task Force Recommendation Statement. (Ann. Intern. Med. 2013:158;478-86).

Ms. Skolnik attends Drexel University, Philadelphia, and is a research assistant at the Children’s Hospital of Pennsylvania. Dr. Clouse is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital.

*Correction 1/23/14: A previous version of this article misstated the name of the American College of Obstetricians and Gynecologists. This version has been updated.