HHAL MEDICAL NEWS APRIL 2011
Diet
and MRI-Confirmed Infarcts in Elders
Among people aged 65 or older, compliance with a Mediterranean diet
significantly reduced the prevalence of brain infarcts.
Scarmeas
N et al. Ann Neurol 2011
Feb 69:257
Alcohol
Lowers Risk for CHD and Mortality
Coronary heart disease and 11-year all-cause mortality were lower with 1 or 2 drinks daily.
Ronksley PE et al. BMJ 2011 Feb 22; 342:d671
Diabetes
Mellitus, Fasting Glucose, and Risk of Cause-Specific Death
The
Emerging Risk Factors Collaboration
CONCLUSIONS
In addition to vascular disease, diabetes is associated with substantial premature death from several cancers, infectious diseases,
external causes, intentional self-harm, and degenerative disorders, independent of several major risk factors.
http://www.nejm.org/doi/full/10.1056/NEJMoa1008862?query=TOC
Long Work Hours Add to Coronary Disease Risk
In
estimating patients' risk for coronary heart
disease, factoring in the length of their workday adds modestly, but significantly, to the sensitivity of their Framingham
score, according to anAnnals of Internal Medicine report.
Using
a cohort of some 7000 British civil servants without apparent coronary
disease at baseline, researchers gathered information to ascertain
Framingham risk scores as well as the number of hours worked in a typical day. Follow-up lasted a median of 12 years. After
adjustment for Framingham scores, participants working 11 or more hours per day had a 67%
increased risk for coronary disease, compared with those working the normal 7 or 8 hours.
The
authors caution that "further testing is needed to confirm the added value of information on long working hours for clinical
decision making."
Annals
of Internal Medicine article
HDL
and Colorectal Cancer Risk
HDL levels were
inversely associated with colon cancer risk but showed no association with rectal cancer risk.
van
Duijnhoven FJB et al. Gut 2011
Mar 7;
Long-Term
Statin Therapy Does Not Lower Risk for Atrial Fibrillation
Several factors might explain
discrepant results between short-term and long-term trials.
Rahimi K et al. BMJ 2011 Mar 16; 342:d1250
Value
of GFR and Albuminuria in Predicting Cardiovascular Outcomes
Glomerular filtration rate and albuminuria
did not add value to traditional risk factors.
Multiple studies have shown that albuminuria and low estimated glomerular filtration
rate (eGFR) predict development of adverse cardiovascular outcomes. Using data from two large studies — ONTARGET (JW Gen Med Sep 2 2008) and TRANSCEND (JW Cardiol Sep 17 2008) — involving more than 27,000 patients (age, >55) who had vascular disease ordiabetes with symptoms of end-organ involvement, researchers evaluated whether eGFR and
albuminuria added predictive power beyond that of traditional risk factors.
Mean follow-up
was 4.6 years. Low eGFR and elevated urine albumin–creatinine ratios were associated with excess risk for cardiovascular-related death, myocardial infarction, stroke, or hospitalization
for heart failure. However, after controlling
for traditionalcardiovascular risk factors (i.e.,
age, sex, diabetes, cardiovascular disease,
smoking status, blood glucose and LDL cholesterol levels), addition of eGFR or urine albumin–creatinine ratio failed
to improve classification of individuals who did or did not experience adverse cardiovascular outcomes during follow-up.
Medline abstract
Clase CM et al. Ann
Intern Med 2011 Mar 1; 154:310
PSA
Velocity: A Criterion for Prostate Biopsy?
Adding prostate-specific antigen velocity as a trigger for biopsy did not improve
predictive accuracy beyond that of using PSA values alone.
Vickers
AJ et al. J Natl Cancer Inst 2011
Mar 16; 103:462
Yao SL and Lu-Yao
GL. J Natl Cancer Inst 2011
Mar 16; 103:450
ACC/AHA Offer Expert
Consensus on Treating Hypertension in
the Elderly
There is little
evidence on which to base guidelines for treating hypertension in the elderly, so instead, the American College of Cardiology and the American
Heart Association (and related societies) offer an "expert consensus"
in the Journal of the American College of Cardiology.
The
consensus, in brief, is that the diagnosis of hypertension be based on at least three measurements of blood pressure, taken on at least two separate office visits. The clinician's task is to identify
reversible or treatable causes, determine if there is organ damage, evaluate other cardiovascular
risk factors, and identify barriers to treatment adherence. The treatment goal is
<140/90 mm Hg.
Treatment may consist simply of lifestyle modification. When
drug therapy is warranted, it should usually begin with a diuretic. When blood pressure is >20/10 mm Hg above the goal,
JACC article (Free PDF)
Omega-3s Associated with Some Prostate Cancers
Patients may ask about a study that unexpectedly links anti-inflammatory
omega-3 fatty acids with high-grade prostate cancer.
Proinflammatory trans-fatty acids showed — also unexpectedly — a protective effect. The results appear in the American Journal of Epidemiology.
In
a nested, case-control study within the Prostate
Cancer Prevention Trial, researchers examined the proportions of serum fatty acids in 1800 men with invasive prostate
cancer and1800 matched controls. At the outset
of the 7-year study, all participants had been cancer-free.
For the omega-3 fatty acid docosahexaenoic acid, each quartile
of serum concentration above the lowest quartile "was associated with an approximate doubling of high-grade disease."
For the 18:1 and 18:2 trans-fatty acids, a protective effect was
found.
Calling their findings "disconcerting," the authors say that much more study
will be needed before changing dietary recommendations.
American
Journal of Epidemiology article
Exercise, no diet and lipoproteins. Go beyond the plasma levels.
This investigation adds relevant information
about the dissociation between quantitative and qualitative aspects of high-density lipoprotein cholesterol after short-term
exercise training without any specific diet in the metabolic syndrome. The findings highlight the importance of evaluating
the functional aspects of the lipoproteins besides their plasma levels. The American Journal of Cardiology
Treating obesity. What family physicians can do.
The combination of phentermine
and topiramate(topamax), with office-based lifestyle interventions, might be a valuable treatment for obesity that can be provided by family doctors. The Lancet
Obesity
and Overweight Are Associated with Diastolic Dysfunction
This finding held even when
other risk factors were taken into account.
Russo C et al. J
Am Coll Cardiol 2011 Mar 22; 57:1368
Adolescent
BMI Associated with Heart Disease in Adulthood
Elevated BMI in adolescence
and in adulthood are independent risk factors for coronary
heart disease.
Tirosh A et al. N Engl
J Med 2011 Apr 7; 364:1315
Measures
of Adiposity Add Little to Standard Predictors of Cardiovascular Risk
Waist-to-hip ratio and body-mass index were equally predictive.
The Emerging Risk Factors Collaboration. Lancet 2011 Mar 26; 377:1085
CONCLUSIONS
In this randomized trial, there was no significant difference between medical
therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned
to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes
and of death from any cause or hospitalization for cardiovascular causes.
http://www.nejm.org/doi/full/10.1056/NEJMoa1100356?query=TOC&
Levothyroxine Dosing Associated with Increased Fracture Risk in the Elderly
Elderly patients receiving levothyroxine show a dose-related
increased risk for fracture, according to a BMJ study.
An accompanying editorial says that the risk is small and the main concern is defining the proper "normal" thyroid-stimulating hormone (TSH)
level in this age group.
Using Ontario's prescription-benefit database, researchers
conducted a case-control study among more than 200,000 adults (mean age, 82) who were using thyroxine any time over a 5-year
period. Current and recent thyroxine use (within the past 6 months) were both associated with an increased risk for fracture,
compared with remote use (discontinued more than 6 months previously). Both high and medium cumulative doses showed increased
fracture risk over low doses.
Editorialists criticize the lack of TSH data — a limitation
the authors acknowledge — and point out that "elderly people need relatively low thyroxine doses, so serum TSH
should be regularly monitored and a suppressed TSH should be avoided in such patients."
BMJ article
Angiotensin II receptor blockers. What else do they do?
This study concludes that long-term use of
angiotensin II receptor blockers is associated with a lower incidence of cancer occurrence,
thereby suggesting that angiotensin II receptor blockers may prevent cancer development. The American Journal of Cardiology
Vitamin
D Deficiency and Anemia in Older Men and Women
VDD was associated with specific subtypes of anemia, particularly anemia of inflammation.
Perlstein TS et al. Blood 2011 Mar 10; 117:2800
Vitamin D insufficiency: Treat everyone
Given that vitamin D insufficiency exists in
most people living in mid- or high-latitude countries, and that vitamin D could exert multiple major preventive actions, the
authors recommend that vitamin D supplementation should be organized in these countries to treat all those currently in a
state of insufficiency, patients and 'normal' subjects alike, without further delay. (Abstract and article in English;
abstract in French) Masson/La Presse Medicale
Some benefits continue after estrogen-only therapy withdrawal
Data from the Women's Health Initiative indicate that four
years after stopping estrogen-only therapy in women who had a hysterectomy, the increased risks of stroke and blood clots
in the legs had dissipated. The reduced risk of breast cancer held steady, but the decreased risk of hip fracture seen while
taking the estrogen-only therapy reverted to baseline four years after the intervention, according to the study in the Journal
of the American Medical Association.Los Angeles Times
WHI Researchers Examine
Risks During and After Estrogen Therapy
The
effects of estrogen therapy on certain health outcomes seem to disappear after therapy is discontinued, according to an analysis
from the Women's Health Initiative in JAMA.
The
analysis involved postmenopausal women who'd had hysterectomies and were randomized to receive conjugated equine estrogens
or placebo. Researchers examined health outcomes during roughly 6 years of estrogen use and 4.5 years afterward. Among the
findings:
·
The increased risks for
stroke and venous thromboembolism observed
during treatment diminished after treatment ended.
·
When breast cancer risk
was considered for the entire 10.5 years' follow-up, a significant reduction in risk emerged.
·
Over the whole follow-up,
estrogen use was associated with lower cardiac risk in women aged 50 to 59, but not older women.
Journal Watch Women's Health Editor-in-Chief Dr. Andrew Kaunitz says the findings "provide ... reassurance to young menopausal women who are
posthysterectomy and who present with bothersome vasomotor
symptoms that use of estrogen therapy for as long as 6 years is safe."
JAMA article
Systolic blood pressure: Always an important clue.
This study concluded that
in patients with mild to moderate chronic systolic and diastolic heart failure, baseline SBP ≤ 120 mm Hg was associated
with increased cardiovascular and heart failure mortality and all-cause, cardiovascular and heart failure hospitalization
independent of other baseline characteristics. The American Journal of Cardiology
Blood pressure is lowest in the morning, study finds
Data on 28 people without
high blood pressure found that their blood pressure peaked at about 9 p.m. daily and reached
its lowest level in the late morning. The study in the journal Circulation suggests that variations in blood pressure levels
may not be responsible for the documented increased risk of having a heart attack or stroke in the morning. U.S. News & World Report/HealthDay News
Simvastatin and fenofibrate: Can they prevent vascular complications?
This article reports that simvastatin
and fenofibrate exhibit a similar effect on the secretory function of human monocytes and lymphocytes and on systemic inflammation
in type 2 diabetic subjects with mixed dyslipidemia. This effect may be clinically relevant in the prevention of vascular
complications in metformin- and diet-treated subjects with newly diagnosed diabetic dyslipidemia. The American Journal of Cardiology
B Vitamins
for PMS?
Higher
dietary intake of thiamine and riboflavin was associated with lower risk for new-onsetpremenstrual
syndrome during 10 years of follow-up in the Nurses'
Health Study
The etiology of premenstrual syndrome (PMS) remains elusive. To evaluate
possible associations between dietary B vitamin intake and development of PMS, investigators conducted a case-control study
nested within the Nurses' Health Study, a longitudinal cohort of women who provide biennial reports of diet and lifestyle
factors and health outcomes. During 10 years of follow-up, PMS was diagnosed in 1057 participants (36%); 1968 women were identified
who did not have PMS or other menstrual symptoms.
Women in the highest quintile of thiamine
intake were 25% less likely to develop PMS than were those in the lowest quintile, and women in the highest quintile of riboflavin
intake were 35% less likely to develop PMS. Intake of B vitamins from supplements did not lower risk for PMS — probably
a reflection that such supplements often are prescribed for management of PMS.
http://www.ncbi.nlm.nih.gov/pubmed/21346091?dopt=Abstract
Definition of Alzheimer's Recast for First Time in Over 25
Years
Patients may ask
about a widely reported recasting of the definition of Alzheimer's
disease that, according to the Washington
Post, "could at least double the number of Americans receiving a diagnosis of Alzheimer's and its early phases."
The
criteria were first established in 1984, and the new definition, as recommended by working groups from the National Institute on Aging and the Alzheimer's Association, incorporates biomarkers such as beta-amyloid and tau proteins and acknowledges the disease's
different stages. According to the reports published online in the journal Alzheimer's
& Dementia, the disease has three stages:
·
a preclinical phase
·
a predementia phase of mild cognitive impairment
·
a dementia phase
The
recommendations acknowledge that the preclinical phase is poorly defined and that "much additional work needs to be done
to validate the application of biomarkers."
Alzheimer's
& Dementia introduction to recommendations (Free PDF)
Alzheimer's Association links to new diagnostic criteria (Free)
Washington
Post story (Free)
New
York Times story (Free)
Orthostatic Hypotension
in Older Adults
The prevalence was surprisingly high.
Orthostatic hypotension is common in older adults, particularly among those taking hypotensive
medications and those with diseases associated with autonomic dysfunction (e.g., diabetes, Parkinson disease). In this study
from Ireland, researchers used a continuous noninvasive blood pressure (BP) monitoring device to measure orthostatic change
on a single occasion in 442 community-dwelling, older adults (mean age, 72).
Mean baseline supine
systolic BP (SBP) was 160 mm Hg. The changes from supine to standing SBP conformed to three general patterns:
·
"Small drop, fast
overrecovery" (25% of participants): mean SBP drop within 30 seconds, 16 mm Hg; quick recovery exceeding baseline SBP
at 30 seconds
·
"Medium drop, slow
recovery" (54% of participants): mean SBP drop within 30 seconds, 35 mm Hg; return to near-baseline SBP at 30 seconds
and at 2 minutes
·
"Large drop, nonrecovery"
(21% of participants): mean SBP drop within 30 seconds, 62 mm Hg; gradual but incomplete return to baseline SBP during 2 minutes
of monitoring
Eighty-five participants met a previously published definition of "initial
orthostatic hypotension" — a symptomatic SBP drop of >40 mm Hg within 15 seconds (Clin Sci (Lond) 2007; 112:157). These elders, compared with other participants, were more likely to have fallen
recently (25% vs. 10%), to be taking >4 medications (54% vs. 39%), and to meet criteria for frailty or prefrailty (71%
vs. 52%).
http://www.ncbi.nlm.nih.gov/pubmed/21438868?dopt=Abstract
Oxymetazoline(Afrin)
Boosts Intranasal Steroids' Effects Without Rebound Congestion
Good news for patients with
severe nighttime nasal congestion
Baroody FM et al. J Allergy Clin Immunol 2011 Apr 127:927
Statin
Use and Risk for Death After Pneumonia
Statin users were significantly less likely to die in the 6 months after pneumonia
diagnoses.
Douglas I et al. BMJ 2011 Apr 6; 342:d1642
COPD
— Not Just in Smokers
Among never-smokers, 12% had spirometric evidence of chronic obstructive pulmonary disease.
Lamprecht
B et al. Chest 2011
Apr 139:752
Impaired lung function: A heart failure clue
These authors report that abnormal spirometric
findings in older adults without clinical lung disease are associated with increased heart failure risk. The American Journal of Medicine
Total
Hip Replacement in Morbidly Obese Patients
Self-reported functional outcomes were comparable to those of nonobese patients.
McCalden RW et al. J
Bone Joint Surg Br 2011 Mar 93-B:321
Study
finds declining mortality rate for people with hypertension
Data on almost 23,000 adults indicate the mortality rates of those with high blood pressuredeclined from 18.8 per 1,000 person-years in the 1971 to 1975 time period to 14.3 per 1,000 person-years in the 1988
to 1994 period. But adults with hypertension still
had at least a 42% higher mortality rate compared
with people without hypertension during the time frames, as well as a 45% lower reduction in cholesterol
levels and a higher risk of developing diabetes, the study in the journal Circulation found.
http://consumer.healthday.com/printer.asp?AID=652255
Study looks at spread of herpes virus
Data on 498 people with
herpes simplex virus type 2 indicate that those who had experienced symptoms of genital herpes had the ability to pass the
virus 20.1% of the time. Participants who had been asymptomatic were infectious only 10.2% of the time, but 84% of that window was when they didn't exhibit any symptoms, the study in the Journal of the American
Medical Association found. TIME/Healthland blog
Antidepressants and reduced myocardial infarction risk. What's
the connection?
Across classes of antidepressants, 12 weeks of pharmacotherapy
appears to be safe in terms of MI risk. Although the mechanism for this association remains uncertain, it is possible that
compliance with pharmacotherapy for depression reflects compliance with cardiovascular medications. It also is possible that
a direct drug effect or improved depressed mood may attenuate the risk of MI in depressed patients. The American Journal of Medicine
Do Calcium Supplements Increase
Heart Risk?
The Answer Proves Elusive
Calcium
supplements "modestly" increase cardiovascular risk, and their use in managingosteoporosis ought to be reexamined, according to aBMJ article.
Editorialists, however, declare that the "debate remains ongoing."
Researchers first
examined data from the Women's Health Initiative (WHI) study on calcium and vitamin D supplementation. They found that half the participants were taking personal calcium supplements
at randomization, whether they were assigned to calcium plus vitamin D or placebo.
Among the women
not taking personal supplements at randomization, assignment to calcium supplements was associated with increased risk for
cardiovascular events. When data on those women were combined with data from eight other randomized trials, calcium remained a source of risk. The authors
estimate that treating 1000 people with calcium supplements for 5 years would lead to six additional MIs or strokes while
preventing three fractures.
Editorialists worry that focusing on the WHI participants
not taking personal supplements may have affected the integrity of the findings and therefore call for further study.
BMJ article
Pioglitazone to Prevent Progression to Diabetes
This drug lowered
risk for progression but raised risk for edema and weight gain.
Patients
with impaired glucose tolerance are
at elevated risk for adverse cardiovascular events and progression to diabetes. To assess whether pioglitazone (Actos) can prevent or slow progression to diabetes, Texas
researchers randomized 602 patients with impaired glucose tolerance to placebo or pioglitazone (starting dose of 30 mg, titrated
to a target of 45 mg daily). Mean follow-up in this industry-supported trial was 2.4 years.
More
placebo recipients (17%) than pioglitazone recipients (5%) progressed to diabetes. Mean glycosylated hemoglobin (HbA1c)
levels rose by 0.2% in the placebo group and remained unchanged in the pioglitazone group. Carotid intima–media thickness
increased more slowly in the pioglitazone group. Pioglitazone recipients had more edema (13% vs. 6%) and greater weight gain
(3.9 kg vs. 0.8 kg). The rate of congestive heart
failure did not differ between groups.
Medline abstract (Free)
FDA: Benefits of Olmesartan Outweigh Potential Risk for Cardiovascular
Death
The benefits of
olmesartan (Benicar) "continue to outweigh its potential risks when used for the treatment of patients with high blood pressure according to the drug label,"
the FDA announced on Thursday.
The agency began a safety review of the angiotensin-receptor blocker in June 2010 after two studies showed a higher rate of cardiovascular death among patients
taking olmesartan, compared with those taking placebo; the trials aimed to show whether olmesartan would slow progression
of kidney disease in
patients with diabetes. In its update on Thursday,
the FDA cautions against using olmesartan to delay or prevent microalbuminuria in patients with diabetes.
The
agency advises that clinicians "follow the recommendations in the drug label" when prescribing the drug. The manufacturer
has agreed to conduct further studies on olmesartan's cardiovascular risk profile.
FDA MedWatch alert
Experts Issue Guidelines on Treating Painful Diabetic Neuropathy
Pregabalin
should be offered for the treatment of painful diabetic neuropathy (level A evidence), according to new guidelines from the American Academy of Neurology, American Association
of Neuromuscular and Electrodiagnostic Medicine, and the American
Academy of Physical Medicine and Rehabilitation.
Among the other recommendations
(level B or C evidence), published in Neurology:
·
Anticonvulsants: Gabapentin and valproate should be considered for treatment, while evidence is insufficient to recommend
for or against using topiramate. Oxcarbazepine, lamotrigine, and lacosamide "probably" should not be given.
·
Antidepressants: Amitriptyline, venlafaxine, and duloxetine should be considered, and venlafaxine can be added to gabapentin.
Evidence is insufficient to recommend for or against other agents (e.g., fluoxetine).
·
Opioids: Dextromethorphan, morphine sulfate, tramadol, and oxycodone should be considered.
·
Other pharmacologic
agents: Capsaicin or the Lidoderm
patch may be considered.
·
Nonpharmacologic methods: Electrical stimulation should be considered, while magnetic field treatment is not recommended.
Neurology article
PPIs Help Adult Asthma Physiology, but Not Symptoms, Analysis Finds
Routine use of proton-pump inhibitors in asthma significantly improves physiologic measures
of airway flow, but it doesn't similarly improve patients' symptoms or quality of life, according to anArchives
of Internal Medicine meta-analysis.
Researchers
examined data from 11 randomized trials including some 2500 adult patients. Morning peak expiratory flow rates improved
significantly more among those taking PPIs, especially among patients with confirmed gastroesophageal reflux. However, symptom scores and quality-of-life measures did not show an advantage
for PPI treatment.
The authors argue that their analysis provides a 20-fold increase in available
data compared with older analyses, but they conclude: "There is insufficient evidence to support the routine use of PPIs
in the treatment of asthma."
Archives
of Internal Medicine article
