The past year brought major changes in preventive standards for anxiety, HIV, and RSV along with new guidelines for the treatment of atrial fibrillation. For insight into the effect on internal medicine, we turned to Sarah Candler, MD, MPH, a Houston internist who specializes in the care of high-risk older adults.
Q: Which new prevention guidelines had the most impact on you over the past year?
A: I'm a primary care doctor, and most of the internal medicine updates that are interesting to me focus on how we can keep people from getting sick in the first place. That's especially important in light of the fact that we had a decrease in life expectancy of 2 years [it finally rose slightly in 2022] and widening of the gender gap in life expectancy for men and women.
I'm excited to see new recommendations from the US Preventive Services Task Force, including a new one about using PREP [pre-exposure prophylaxis] to preventively treat anyone who's at risk for getting HIV. That's a big one because it's one of the first times that we've identified at-risk groups for screening based on social risk factors, not gender, age, or genetics.
The new recommendation is PREP for anyone who's at risk for getting HIV because they have a partner with HIV, had an sexually transmitted infection in the last 6 months, or a history of inconsistent or no condom use with partners with unknown HIV status.
PREP therapy is something that most primary care physicians can either do or learn how to do pretty easily. But the treatment does require maintenance and monitoring.
Q: How firm is this recommendation?
A: The task force gives different grades for their recommendations based on how strong the evidence is. For the guidelines about PREP, they give a grade of A. That means this is top of the class: You should definitely do this.
Q: What are the best strategies to ask patients personal questions about their sex lives in order to evaluate their risk?
A: A lot of internal medicine physicians are getting pretty good at this. We see it as part of our job just the same way as we asked things like, "How often are you walking?" and "Have you been feeling down?"
There's no one right way to have a conversation like that. But it's key to say, as I do to my patients, that "I'm not here to judge anything. I am truly here to gather information and make recommendations to you as a partner in your care."
Q: What other guidelines made an impact in 2023?
A: The US Preventive Services Task Force made a recommendation to screen adults aged 18-64 for anxiety, and this guidance got a B grade. [The task force said there's not enough evidence to support routine anxiety screening in adults 65 and older.]
The new recommendations is a sign that we're doing a better job at making treatment of those diseases more acceptable. This is also another example of the medical community recognizing that internal medicine physicians are pretty good at identifying and treating mental health.
Q: How do you figure out whether to treat depression/anxiety yourself or refer patients to specialists?
A: As a primary care physician, I feel comfortable diagnosing and managing some mental health disease in my own practice. There are FDA-approved medications for both anxiety and depression that are easily managed by a primary care physician.
And there's something to the therapeutic relationship, to naming and identifying these conditions with your patients. Some patients feel a bit of relief just knowing that they have a diagnosis.
Q: What should internists know about the new CDC guidelines that promote discussing RSV vaccines with patients who are over 60?
A: The vaccines are recommended for folks who have underlying conditions like lung disease or heart disease. Those are the ones who end up getting really, really sick. There are two adult vaccines that are available, and there's not a preference for one over the other.
The vaccines are both protein-based, like the old-school versions of vaccines, not the mRNA vaccines that we've all been hearing more about through COVID. Anybody who's reluctant to take an mRNA vaccine can rest assured that the RSV is not protein-based. And they are single-dose vaccines, which is helpful.
Q: What else should internists know about that was new in 2023?
A: I'm super excited about how cardiologists are thinking about atrial fibrillation. In 2023, the American College of Cardiology and the American Heart Association came up with a giant overhaul of how they look at atrial fibrillation. They classify it in stages and allows us to think about stopping it before it starts.
They're talking about something they're calling preclinical or subclinical atrial fibrillation, which you may detect on wearables like somebody's watch or another tool used to monitor heart rate or exercise. It might be the first harbinger that there's something wrong with the heart rate, and they may not even have symptoms of it. [A 2023 study in The New England Journal of Medicine linked the anticoagulant apixaban, or Eliquis, to a 37% lower risk of stroke and systemic embolism rates in older patients with subclinical atrial fibrillation but an 80% higher risk of major bleeding vs. aspirin therapy.]
And they're now recommending early rhythm control.
Q: What does early rhythm control mean for patients and physicians?
A: For the longest time, we have thought about atrial fibrillation treatment in terms of rate control and not worrying too much about the rhythm. But now we recognize that it's actually really important that we get the rhythm under control because physical changes to the heart can lead to permanent damage.
So now they're recommending catheter ablation as first-line therapy in some patients as a class 1 recommendation because heart function is already decreased. Improving the ability of the heart to beat with a regular rhythm can lead to improvement of function. This was unheard of even 5 years ago.
Q: Should internists be more willing to refer patients with atrial fibrillation to cardiologists?
A: Yes, I think so. One of the biggest changes for me is that I am going to refer new diagnoses of atrial fibrillation to a cardiologist. And I'm going to ask patients if they have wearable devices because sometimes those things might tell me about something like subclinical atrial fibrillation.
Q: There's also detailed data about atrial fibrillation risk factors, which include older age, smoking, sedentary lifestyle, alcohol use, diabetes, height, obesity, diabetes, and others. Is this information useful?
A: It's a really great tool to have in the arsenal because it helps me have shared decision-making conversations with my patients in a way that's much more convincing. A patient might say, "Why do you care if I drink so much? My liver levels are fine." And I can say, "It's going to be a risk factor for having problems with your heart."
For better or worse, people really take the heart very seriously, I am an internal medicine physician, so I love all the organs equally. But man, people get pretty scared when you tell them something can affect their heart. So when I talk to patients about their risk factors, it's going to really be helpful that I can remind them of the impact that some of these lifestyle behaviors can have on their heart health.
Dr Candler has no disclosures.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
Comments