ACOG Bulletin on Selective Estrogen-Receptor Modulators

The American College of Obstetricians and Gynecologists (ACOG) has issued a practice bulletin on the use of selective estrogen-receptor modulators (SERMS) for chemoprevention and treatment of breast cancer and osteoporosis. ACOG Practice Bulletin 39 appeared in the October 2002 issue of Obstetrics and Gynecology.

SERMS, synthetic compounds that bind estrogen receptors and produce agonistic activity in some tissues while acting as estrogen antagonists in others, are often referred to collectively, although their effects in different organs are far from uniform. Four SERMS are approved for use in the United States: clomiphene, tamoxifen, toremifene, and raloxifene.

Among the ACOG recommendations are the following:

• Consideration should be given to tamoxifen therapy for women at high risk of developing breast cancer.

• Raloxifene is appropriate therapy for women who are candidates for chemoprevention of osteoporosis.

• Raloxifene is appropriate therapy to prevent fractures in women with established osteoporosis.

• Neither raloxifene nor tamoxifen should be used in women with a history of venous thromboembolic events, including pulmonary emboli, deep venous thrombosis, or retinal vein thrombosis.

• Any abnormal uterine bleeding should be investigated in women taking tamoxifen or raloxifene.

• Women who have completed a five-year course of tamoxifen therapy should have an individual assessment of their risk for osteoporosis, and decisions about prevention or treatment should be made accordingly.

• The use of tamoxifen or raloxifene should be limited to five years.

• Co-administration of local vaginal estrogen therapy may be used to relieve vaginal dryness in patients receiving raloxifene or tamoxifen therapy.

• Individualized risk assessment should be performed to determine whether a patient is a candidate for breast cancer chemoprevention, unless she has ductal carcinoma in situ or lobular carcinoma in situ, in which case the benefit of chemoprevention already has been documented.

International Family Medicine Poster Presentation

Guidelines for Implantation of Cardiac Pacemakers

The American College of Cardiology, the American Heart Association, and the North American Society for Pacing and Electrophysiology have issued updated guidelines on implantation of cardiac pacemakers and antiarrhythmia devices. The recommendations appeared in the October 15, 2002, issue of Circulation.

The report also includes an updated section on the selection of pacemakers and implantable cardioverter-defibrillators and a summary of pacemaker follow-up procedures. Many of the groups' 1998 recommendations were updated, and several new recommendations were added.

The new guidelines recommend pacing therapy for the following groups:

• Adults with neuromuscular diseases, such as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb's dystrophy (limb-girdle), and peroneal muscular atrophy with any degree of fascicular or atrioventricular (AV) block (including first-degree AV block), with or without symptoms.

• Adults with alternating bundle-branch block.

• Adults with syncope of unexplained origin when major abnormalities of sinus node function are discovered or provoked in electro-physiologic studies.

• Adults with significantly symptomatic and recurrent neurocardiogenic syncope associated with bradycardia documented spontaneously or during tilt-table testing.

• Children with congenital heart disease and impaired hemodynamics because of sinus bradycardia or loss of AV synchrony.

• Children with neuromuscular diseases with any degree of AV block, with or without symptoms.

Implantable cardioverter-defibrillator implantation is recommended for patients with the following conditions:

• Spontaneous sustained ventricular fibrillation that is not amenable to other treatments. It is recommended only in the absence of structural heart disease.

• Left ventricular ejection fraction of 30 percent or less, at least one month post-myocardial infarction and three months post-coronary artery revascularization surgery.

• Syncope of unexplained etiology or family history of unexplained sudden cardiac death in association with typical or atypical right bundle-branch block and ST-segment elevations (Brugada syndrome).

• Syncope in the presence of advanced structural heart disease in which thorough invasive and noninvasive investigation has failed to define a cause.

Biventricular pacing therapy is recommended for patients with advanced heart failure, specific indexes of left ventricular dysfunction, and prolonged QRS duration.

Call for Papers of Family Practice Research Presentations

Management of Patients with Unstable Angina

The American College of Cardiology and the American Heart Association have updated their September 2000 guidelines on management of unstable angina and non–ST-segment elevation myocardial infarction (MI). The updated guidelines appeared in the October 1, 2002 issue of Circulation.

Among the recommendations:

• Hospitalized patients for whom an early noninterventional approach is planned should be given clopidogrel and aspirin for at least one month and for up to nine months.

• Patients who will undergo catheterization and percutaneous coronary intervention (PCI) should be given a platelet glycoprotein (GP) IIb/IIIa antagonist with aspirin and heparin. The GP IIb/IIIa antagonist also can be given just before PCI.

• Patients who will undergo PCI and who are not at high risk for bleeding should be given clopidogrel for at least one month and for up to nine months.

• Patients taking clopidogrel who will undergo elective coronary artery bypass grafting (CABG) should not take the drug for five to seven days before the procedure.

• Patients who have continuing ischemia, an elevated troponin level, or other high-risk features and for whom an invasive management strategy is not planned should be given eptifibatide or tirofiban with aspirin and low-molecular-weight heparin or unfractionated heparin.

• Patients already taking heparin, aspirin, and clopidogrel who will undergo catheterization and PCI should be given a platelet GP IIb/IIIa antagonist. The GP IIb/IIIa antagonist also may be given just before PCI.

• Patients without continuing ischemia who have no other high-risk features and in whom PCI is not planned should be given eptifibatide or tirofiban and aspirin and low-molecular-weight heparin or unfractionated heparin.

• Patients without acute ST-segment elevation, a true posterior MI, or a presumed new left bundle-branch block should be given intravenous fibrinolytic therapy.

• Patients who will not undergo PCI should be given abciximab.

• Anticoagulation with subcutaneous low-molecular-weight heparin or intravenous unfractionated heparin should be added to anti-platelet therapy with aspirin and/or clopidogrel.

• Enoxaparin is preferred over un-fractionated heparin as an anticoagulant for patients with unstable angina and non–ST-segment elevation MI, in the absence of renal failure and unless CABG is planned within 24 hours.

ACOG Recommendations on Shoulder Dystocia

Shoulder dystocia, or failure of fetus shoulders to deliver spontaneously, cannot be predicted or prevented, and elective cesarean delivery or induction of labor for every woman suspected of carrying a macrosomic fetus is not appropriate, according to recommendations from a committee of the American College of Obstetricians and Gynecologists (ACOG). ACOG Practice Bulletin 40 appeared in the November 2002 issue of Obstetrics and Gynecology.

Although fetal macrosomia and maternal diabetes increase the risk of shoulder dystocia, a substantial number of cases occur in women who do not have diabetes and among infants weighing less than 8.8 lb (4,000 g). In one study, the presence of both diabetes and macrosomia predicted only 55 percent of cases of shoulder dystocia.

Antepartum conditions associated with shoulder dystocia include maternal obesity, multiparity, post-term gestation, history of a macrosomic birth, and history of shoulder dystocia. Associated intrapartum conditions include labor induction, epidural anesthesia, and operative vaginal delivery (forceps and vacuum-assisted delivery). In each case, risk factors can be identified, but their predictive value is not high enough to be useful.

In patients with a history of shoulder dystocia, estimated fetal weight, gestational age, maternal glucose intolerance, and the severity of the prior neonatal injury should be evaluated, the ACOG committee recommended. The risks and benefits of planned cesarean delivery should be discussed with the patient.

Planned cesarean delivery to prevent shoulder dystocia may be considered for suspected fetal macrosomia with estimated fetal weights of more than 5,000 g (11 lb) in women without diabetes and 4,500 g (9.9 lb) in women with diabetes, the committee stated.

There is no evidence that any maneuver is superior to another to release an impacted shoulder or to reduce the chance of injury, the committee found. However, the McRoberts maneuver is a reasonable initial approach, it stated.

NAMS Guidelines on Hormone Therapy

An advisory panel of the North American Menopause Society (NAMS) has issued recommendations on the use of postmenopausal hormone replacement therapy. The report is available online atwww.menopause.org.

The report is based on data from two recent large clinical trials—the Heart and Estrogen/progestin Replacement Study (HERS) and the Women's Health Initiative (WHI)—that have altered the benefit-risk ratio for postmenopausal hormone replacement therapy, especially in women at risk for coronary heart disease.

Panelists noted that in published data from HERS and WHI, only one hormone therapy was used, a popular estrogen-progestogen therapy (EPT) for women with an intact uterus. The trials used only one route of administration and only one regimen. Neither trial evaluated perimenopausal women or women with early or premature menopause.

The NAMS panel concluded that physicians should not prescribe EPT for primary or secondary prevention of coronary heart disease and that estrogen therapy (ET) should not be used for this purpose until confirming data are available. Other recommendations included the following:

• Prescribing progestogen only for women with an intact uterus who are using ET.

• Creating an individual risk profile for every woman considering EPT or ET.

• Considering alternatives to EPT and ET for preventing postmenopausal osteoporosis.

• Limiting EPT and ET to the shortest duration consistent with treatment goals, benefits, and risks for each patient.

• Considering lower-than-standard doses of EPT and ET.

AHRQ Report on Smoking with Chronic Conditions

A substantial number of smokers who report having a diagnosed chronic condition continue to smoke despite their health problems, according to a new report from the Agency for Healthcare Research and Quality (AHRQ).“Smoking Status of Adults—United States, 2000” is available online atwww.meps.ahrq.gov.

According to the report, about 38 percent of people with emphysema, 25 percent of people with asthma, 20 percent of people with hypertension or cardiovascular problems, and 18.5 percent of people with diabetes reported in 2000 that they continued to smoke. In addition, three out of five smokers who also had the chronic conditions listed above reported that their doctor had advised them in the previous 12 months to stop smoking. Overall, about 57 percent of smokers who had a routine checkup in the previous 12 months were counseled by a physician to stop smoking.

The report cites new data from a self-administered questionnaire added to the AHRQ's Medical Expenditure Panel Survey (MEPS) in late 2000 and early 2001 to collect information on health care quality and satisfaction with health care.

The data on smoking in the United States were derived by combining the results of the new questionnaire with demographic, chronic condition, and preventive care information collected by MEPS' nationally representative survey of people more than 18 years of age who are not in the military or living in institutions. More than 15,600 people responded to the survey questions.

The report also stated that almost 24 percent of non-Hispanic blacks and 24 percent of non-Hispanic whites and other people smoked, compared with only 17 percent of Hispanics.