H&P/ SOAP notes:

Internal Medicine – H&P #1

Internal Medicine – H&P #2

Journal Article and Summary:

Vericiguat in Patients with Heart Failure and Reduced Ejection Fraction

Heart failure remains a major burden in the health care system, many patients face a considerable risk of death or recurrent hospitalization. More than one million patients are hospitalized for heart failure (HF) annually in the United States alone, and more than 80% of these hospitalized patients have worsening chronic HF. Despite treatment in hospitals about 25% are re-hospitilized within 30 days, and about 30% die within one year. An issue is adherence to medications however this is challenging because of side effects, thus more treatment options should developed. It is known that in HF, increased inflammation and vascular dysfunction results in reduced nitric oxide bioavailability, with decrease in downstream cyclic guanosine monophosphate (cGMP) synthesis. The decrease of cGMP causes systemic, coronary, and renal dysfunction, which may lead to progressive myocardial damage and further inflammation. Therefore, a correction of this deficit by an oral soluble guanylate cyclase (sGC) stimulator such as vericiguat offer a novel approach for addressing the relative cGMP deficit in worsening chronic HF. These agents modulate sGC, imitating nitric oxide and restoring downstream cGMP synthesis.

In this multinational, randomized, double blind, placebo controlled trial 89% of patients were adherent to the target 10-mg dose of vericiguat after 12 months of the trial. Patients were randomly assigned, in a 1:1 ratio, to 2.5 mg of vericiguat or matching placebo, and then increased to 5 mg and ultimately to 10 mg once daily, target dose. Patients were evaluated at weeks 2, 4, and every 4 months until the end of the trial. Dosing was addressed according to the patient’s blood pressure and symptomatic status. The study’s primary outcome measured was a composite of death from cardiovascular causes or first hospitalization for heart failure. Secondary were subsequent hospitalizations for heart failure, and death from any cause. The study screened a total of 6,857 patients from 42 countries, 1807 were excluded due to not meeting eligibility. Thus 5,050 patients were enrolled and randomized. So 2526 were randomly assigned to receive vericiguat, and 2524 were assigned to receive the placebo. The study found that the incidence of the composite of death from cardiovascular causes or hospitalization for heart failure was lower with vericiguat than with the placebo. Vericiguat was favored after approximately 3 months of treatment and persisted throughout the trial. The 10% relative difference between the groups translated into an absolute event rate reduction of 4.2 events per 100 patient-years. Based on this absolute risk reduction, the number needed to treat with vericiguat for 1 year to prevent a primary-outcome event is approximately 24 patients. The incidence of hospitalization for heart failure was lower with vericiguat than with placebo, and the incidence of death from cardiovascular causes was possibly lower. Also there was no significant between-group difference in the incidence of death from any cause.

Further clinical trials of Vericiguat added on top of standard of care is needed to show a clinically significant reduction in NT-proBNP and a trend towards less hospitalizations for HF. Additional studies with vericiguat should consider longer follow-up, higher doses, and additional prognostic endpoints to clarify its potential impact on clinical outcomes in patients with HF with worsening symptoms. Hypothetically sGC stimulators are likely to be promising add-on strategies for the treatment of heart failure.

Site Evaluation Presentation Summary:

I had the pleasure of meeting the notorious Ronald Combs who was the first PA to be hired at NYPQ and also the first Physician Assistant in the Country to be inducted as a Fellow in the College of Critical Care. During my evaluation we spoke about my Internal Medicine rotation at NYPQ and working along side the PAs. I informed him that being able to work with the Stroke team and round on the stroke unit was a great experience. Additionally working in the ICU was a great experience and something I wished the program allowed us to choose an elective in. He liked the drugs I selected and we went through their mechanism of action and how it helps in certain diseases. One example was the use of heparin and the need to bind to antithrombin III, to inactivation of thrombin and other clotting factors. Being that it is dependent on antithrombin III if someone was deficient in this enzyme then heparin would not be effective. Surprisingly clinicians may need to give patients fresh frozen plasma (FFP) first for the heparin to be operational. I presented a cardiogenic shock and heart failure patient who also tested positive for COVID-19 and was admitted to the ICU for Inotropic, Vasopressor therapy, and monitoring.

What I also enjoyed from the evaluation was his counsel and guidance for students and new grads going into the job market. One thing he said that resonated with me was that as a new grad, it is important to not only find a field/area you are interested in but also to find an environment/setting that fosters learning and growth. He reports that many places may entice you with money but it is best to work somewhere you can learn from peers and where your supervising physician or other clinicians would help and teach you to become a better provider. I hadn’t thought much about that aspect but it was great advice and something to definitely consider.

Typhon Log:

Internal Medicine Typhon Log

Self-Reflection:

Going into my Internal Medicine rotation, I was excited that it was towards the end of my clinical year as I knew it was a good opportunity to learn a lot and also understand what it is like to work in a hospital. This was one of the areas I was interested in working after graduating. I met with the new preceptor, Lyncan Williams and he assigned me to a different floor and PA to work with weekly. Additionally I worked on the stroke consults team one week and was able to work in the ICU for another week. I immediately found out how busy and stressed the PAs were, as their patient census ranged from 13-22 on certain days. I was fortunate to work with a senior PA and previous York College PA graduate, Bilal Hanif. He taught me what to look for in the patients chart and record on his “handoff” or patient list to understand and get a picture of the patient’s hospital course thus far. From there I adopted my own way of analyzing the patients chart and objective that needed to be done. From this rotation I was also able also perform new procedures such as arterial blood gases, fecal occult blood testing, nasogastric tube placement, arterial lines, and such. ABGs were simple in concept but more difficult in practice as you are unable to visually see the artery and a common fault is going too deep and puncturing the artery twice. Like most procedures it takes practice. Moreover I was able to observe a few endovascular thrombectomies and a paracentesis.

I enjoyed my stroke week, although it can be random, it was very busy as we were called to about four different stroke consults a day. It was interesting to see how the ACLS Stroke Algorithm was utilized and performing the NIH Stroke Scale (NIHSS). The attending was great because he would explain the CT results and the vasculature and possible occlusions and what we would expect to see on physical exam. I was present for three cases that administered tissue plasminogen activator (tPA) and also subsequent thrombectomies, which is the removal of a thrombus (blood clot) under image guidance. That was so fascinating to observe as they inserted dye to see the vasculature of the brain, and successive revascularization after a clot or clots are removed. I was able to learn a ton about CVAs and neurology.

Furthermore I would like to reflect on my experience working in the ICU and taking care of COVID-19 positive patients. During my time there critical care PAs were designated to work in the COVID unit. Seeing first hand what this virus does to a persons lungs was shocking. Half the patients were intubated, all of them needed supplemental oxygen from a high flow ventilator or more and most would go into acute respiratory distress syndrome (ARDS). They were treating acute COVID infections with Remdesivir, Dexamethasone, and Convalescent Plasma. Speaking to patients and their loved ones can also be disheartening as you don’t know how the patients condition can progress to get better or worse. One such patient was a 65-year-old Chinese female who was admitted for shortness of breath and required oxygen, she was strong spirited and wanted to know how long she would be at the hospital as she wanted to go home. However only a few days later her condition worsened and she needed to be intubated. Her blood pressure was unstable and she was given multiple medications including pressors. It was because of this that she required an arterial line. PA Dino was amazing, he is a great teacher who is caring of his patients and patient with the students. He allowed me to place the arterial line under US guidance. We attempted her radial artery first but it seemed too constricted, possibly due to the medications. Thus I did a femoral arterial line, which was much like a central line placement. I was thankful for the opportunity as it was a great ending to my rotation. I realized working in critical care you would need to be more knowledgeable of the pathophysiology of how diseases and medications work. I liked to be more hands on and prefer to do procedures, so it is definitely something I would consider in the future.

Two great videos I watched prior to working in the ICU were: