#537 - PTSD Dx and Tx, Heart Failure 2024, Let’s Wonder Together
Take 3 – Practical Practice Pointers©
From the Department of Defense/Veterans’ Administration
1) Guideline for Diagnosis and Management of PTSD
The experience of a traumatic incident – serious accident, assault, war exposure, or disaster - is unfortunately pretty common among US adults, estimated at 70% of the population. Fortunately, only a fraction of those (in the non-military population) develops fully-diagnosed post-traumatic stress disorder (PTSD) – 4% in men, 8% in women.
The US Department of Defense (DoD) and the Veteran’s Administration (VA) have joined forces to produce some of the better evidence-based guidelines for a variety of common conditions since the early 2000s. The first iteration of this guideline on PTSD was published in 2017 and has now been updated.
DoD/VA guidelines generally follow the National Academy of Medicine’s recommendations for trustworthy guidelines closely. This guideline used precise clinical questions, a rigorous evidence search, and GRADE (a widely accepted evidence rating and recommendation system) to formulate their recommendations. In addition, there was a rigorous conflict of interest policy for the guideline members.
The primary care-relevant recommendations, with strength of recommendation in [ ] are:
· Screen for PTSD using the Primary Care Screener for PTSD for DSM-5 [weak].
· Formally diagnose PTSD and follow its course using a structured interview tool (CAPS-5 or PSSI for diagnosis, CAPS-5 or PTSD Checklist for DSM5 for monitoring) [weak].
· For patients diagnosed with acute stress disorder (ASD) after trauma, cognitive behavioral therapy can prevent PTSD [weak]. No other intervention (including medications) has been shown to prevent it.
· Psychotherapy is recommended over pharmacotherapy for treatment of PTSD generally [strong]:
o Cognitive processing therapy, eye movement desensitization and reprocessing and prolonged exposure are [strong] recommendations.
o Ehlers cognitive therapy, present centered therapy, or written exposure therapy are supported by [weak] evidence.
o Telemedicine delivered versions of the above therapies are recommended if needed if that therapy has been validated for telemedicine [strong].
· Pharmacotherapy, if needed:
o Paroxetine, sertraline, or venlafaxine are recommended [strong].
o Avoid benzodiazepines and cannabis [strong].
o Avoid divalproex, guanfacine, ketamine, prazosin, risperidone, tiagabine, vortioxetine and any of the atypical antipsychotics [weak].
o Prazosin can be useful for nightmares [weak].
· Non-pharmacologic therapy:
o Consider mindfulness-based stress reduction (MBSR) [weak].
o Avoid electroconvulsive therapy and vagus nerve stimulation [weak].
· Co-occurring substance use disorder or other behavioral disorders do not preclude the psychotherapies listed above [weak].
· Many other treatments are listed in the guideline, but anything not mentioned here had insufficient evidence to recommend for or against.
John’s Comments:
For the screening and diagnosis tools mentioned, go to the VA’s PTSD site (some require registration). “Screening” for PTSD is not well explained here. It presumably does not mean universal screening, but initial testing when a history of trauma is present and there are suggestive symptoms. The preferred treatment is psychotherapy but, often, when we refer for counseling, we get the techniques the counselor is most familiar with and feels would work best. Still, it can’t hurt to ask for the specific techniques listed above. We can treat a lot of PTSD in primary care – most of the therapies are well within our scope if we have psychotherapy referral available (and I know that’s a big “if”).
Reference:
· Schnurr PP, Hamblen JL, Wolf J, et al. The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med. 2024;177(3):363-374. Link
From the Literature and the American College of Cardiology (ACC)
2) Heart Failure with Reduced Ejection Fraction (HFrEF) 2024
In the US, approximately 115 million people have hypertension, 100 million have obesity, 92 million have prediabetes, 26 million have diabetes, and 125 million have atherosclerotic CVD. These are known risk factors for development of HF, which places a large portion of the US population for at-risk or stage A HF. It is estimated that presently almost 7 million US adults have HFrEF.
In 2022, three cardiology professional societies published a joint updated guideline on the management of HF. The guideline was intended to provide patient-centric recommendations to prevent, diagnose, and manage patients with HF. As follow-up to this, the American College of Cardiology (ACC) recently updated their 2021 expert consensus decision pathway (ECDP) for those with heart failure with reduced ejection fraction (HFrEF = left ventricular ejection fraction [LVEF] ≤40%) that is intended to provide more practical guidance on introducing the numerous evidence-based therapies, improving adherence, overcoming treatment barriers, acknowledging contraindications and situations for which little data exist, affording expensive therapies, treating special cohorts, and making the transition to palliative care. The document focuses primarily on the management of patients with chronic HFrEF in the ambulatory setting and without symptoms or signs of clinical instability.
As a reminder, some notable highlights from the 2022 HF guideline include:
· New classifications for HF include HF with preserved ejection fraction (HFpEF = EF >50%), HF with mildly reduced EF (HFmrEF = EF 41-49%), HF with reduced EF (HFrEF = EF <40%). An additional category, HF with improved EF (HFimpEF) refers to patients with previous HFrEF who now have an LVEF >40%.
· For suspected or new-onset HF, or those presenting with acute decompensated HF, a CXR and a transthoracic echocardiography (TTE) should be performed.
· In patients presenting with dyspnea, measurement of B-type natriuretic peptide (BNP) or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) is useful to support a diagnosis or exclusion of HF. In patients with chronic HF, BNP or NT-proBNP levels are recommended for risk stratification.
· Guideline-directed medical therapy (GDMT) for HFrEF now includes 4 medication classes: a sodium-glucose cotransporter-2 inhibitors (SGLT2i), a beta-blocker, a mineralocorticoid receptor antagonist (MRA - spironolactone), and a renin-angiotensin system (RAS) inhibitor (ACEi, ARB, or ARNi - angiotensin receptor-neprilysin inhibitor: sacubitril/valsartan - Entresto).
· Patients with HFimpEF should continue their HFrEF treatment.
· In patients with HF who have fluid retention, a loop diuretic is recommended to relieve congestion, improve symptoms, and prevent worsening HF.
The new 2024 decision pathway emphasizes that for the person with de novo HFrEF, therapies should be initiated with a goal of reaching target or maximally tolerated doses of the 4 key medication classes as soon as possible, and ideally no longer than 3 months. Since there is no optimal order of initiation and/or titration, clinicians will need to individualize treatment based on the comprehensive clinical and social picture. Table 1 in the document provides helpful guidance on the starting and target doses for medications in each drug class.
The decision pathway also notes some guiding principles which can improve decision-making for and adherence to GDMT. These include:
· GDMT is the foundation of HF care
· Start GDMT immediately and titrate during each encounter.
· Target doses are associated with best outcomes.
· Prioritize addressing clinical, social, and financial barriers to achieving GDMT.
· Diligent management of volume status will reduce patient symptoms.
· Tolerability and side effects depend, in part, on how and when GDMT is prescribed.
· Focus on the patient’s symptoms, functional capacity, and cardiac function.
· The value of a therapy to a patient is the combination of benefits and burdens as they relate to that patient’s values, goals, and preferences.
· Team-based care is critical to optimizing GDMT and may include frequent follow-up visits, telehealth visits, and remote monitoring.
Mark’s Comments:
The decision pathway has some useful tables/algorithms for future reference and provides helpful guidance for med management. My criticism is while it makes a point of discussing access to medications, it downplays just how challenging it is for many to be able to afford some of the medications for GDMT, and in particular any of the SGLT2-inhibitors as well as sacubitril/valsartan (Entresto).
References:
· Heidenreich P, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report sof the ACC/AHA Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. Apr 01, 2022. Full Guideline Executive Summary
· Maddox T et al. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight. J Am Coll Cardiol. Mar 08, 2024 Link
From PeerRxMed ( www.PeerRxMed.org )
3) The Secret of Living Well? Let’s Wonder Together …
“Perhaps the secret of living well is not having all the answers, but in pursuing unanswerable questions in good company.” Rachel Naomi Remen, MD
One of my favorite words is “wonder,” especially the interplay between two of its definitions – to marvel (“wow!”) and to question (“how?”). When I pay attention to this combination of awe and curiosity, magical “surprises” regularly show up for me. And when this happens, I predictably find myself wanting to share these experiences with others.
This is particularly true for my clinical work. The complex workings of the human body and its many manifestations of health and disease overflows with wonder. When I am present and attentive, there are numerous “wonder-filled” moments during my day. This is likely true for you as well. However, in the day-to-day busyness and isolated nature of work, it is easy to put our heads down and just plow through and in the process, not only miss these moments but also the opportunity to share them. Which has left me pondering how I/we might transcend this pattern.
Recently, while working with one of our 3rd year medical students, I decided to very intentionally look for opportunities to embrace this sense of wonderment, and to invite him into that space with me. During one clinical session, we cared for a 100-year old great-great grandmother who shared pictures and stories of her newborn great-great granddaughter, diagnosed hyperthyroidism in a 19-year old with a significantly enlarged thyroid who has likely had it for at least a year, heard the story of a man who had lost 50 pounds in the past 6 months by changing his diet, I&D’d an abscess to profuse thanks, and discussed two instances where cognitive “anchoring bias” had likely led to misdiagnoses. By the end of our time he was wide-eyed with marveling and questioning. It was an exhilarating time that left me reflecting just how different that same clinic would have been had we not shared these moments together.
In her poem "Sometimes", Mary Oliver writes about how to bring more wonder into our days with 7 words of simple yet profound wisdom that she called “Instructions for living a life”:
Pay attention.
Be astonished.
Tell about it.
Each day we have the opportunity to both embrace our amazing professional journey and also to share it with those around us – not only students, but also colleagues, nurses, and even patients. Too often, however, the nature of our work and the manner in which we carry it out leaves our sense of wonder neglected and dulled. Over the next 3 weeks, consider setting an intention of sharing one wonder-full thing a day with someone – perhaps starting with your PeerRx partner. Through pursuing meaningful connection to “marvel and question” together, perhaps the “secret” of living well will no longer be such a secret after all.
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Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.
Email: mhgreenawald@carilionclinic.org