Consider The Evidence: Med/Peds Journal Roundup

April 17, 2008

Yes, Statins do everything – even lower BP

Filed under: archives of internal medicine, hypertension — medblog @ 5:02 pm

What could be crazy enough to end a 4 month hibernation of CTE?

Archives Int Med 4/08 – The UCSD Statin study yielded further evidence that statin treatment reduces blood pressure (although not by much) The RCT enrolled over 900 subjects without known CVD or diabetes. The idea was to independently assess the effect on BP. There was no inclusion / exclusion criteria regarding baseline BP. Subjects were randomized to pravastatin, simvastatin, or placebo.

Treatment with a statin resulted in about a 2-2.5 point drop in SBP and DBP. The treatment was stopped at 6 months, and the blood pressures returned to baseline by month 8 – further suggesting that this was a true effect.

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July 18, 2007

Food for thought: Chocolate to lower BP?

Filed under: cardiovascular, hypertension, JAMA — medblog @ 9:34 am

JAMA 7/4/07 –  Maybe some wizard medicine applies to muggles as well… An article in JAMA by Taubert et al. tests the theory that flavonols found in dark chocolate may lower blood pressure

 The study population consisted of 44 otherwise healthy subjects with upper-range prehypertension or stage 1 hypertension. Patients with any other major medical problems including CVD, diabetes, hyperlipidemia, etc were excluded. Study design was an RCT with investigators blinded, but subjects not – because they couldnt disguise the white and the dark chocolate. Patients were also counseled to abstain from any other cocoa products during the study.  Participants were instructed to take one 5.6(white) or 6.3(dark)  gram piece of chocolate per day.

At 6 weeks – no statistical difference between groups.
12 weeks: dark chocolate group BP was down 2.4/1.3 mmHg from baseline.
At 18 weeks the BP difference in the dark chocolate group was – 2.9/1.9 mmHg.
The white chocolate group: no change.
    
Looks like we have a winner.

For the basic science portion of the study, researchers measured plasma S-nitrosoglutathione. Basically they postulate that this compound is an intermediary between nitric oxide stores and active NO in the endothelium. They also measured 8-isoprostane, a measure of oxidative stress. Levels of S-nitrosoglutathione were significantly increased only in the dark chocolate group. 8-isoprostane levels were unchanged with intervention in both groups. Investigators concluded that the effect of dark chocolate was more likley from stimulation of endothelial NO production rather than changes in redox equilibrium between thiol and nitrosothiols. Big words aside – it seemed to work… at least in a healthy, homogenous, untreated population with mild HTN – although I dont seem to have alot of those in my practice….

November 20, 2006

Thiazides increase Diabetes, ALLHAT says dont worry

Filed under: archives of internal medicine, diabetes, hypertension — medblog @ 11:08 pm

Archives IM 11/13- ALLHAT data first made news with the conclusion that older, thiazide type diuretics were just as effective at reducing hypertension related disease as newer types of anti-hypertensives. One result of the study that is less well known is that thiazides appeared to increase the risk of incident diabetes. In the last issue of Archives, the ALLHAT investigators addressed this issue more directly.[Article]

The investigators performed post hoc analyses on the subgroups assigned to Ca-channel blockers, ACE-Is, and thiazides. Patients with known diabetes prior to start of therapy were excluded from analysis, as were those without baseline fasting blood glucose(FG) levels.

The data shows that all subjects had an increase in FG, but the thiazide group had a significantly greater increase in fasting glucose levels than the other groups. In addition, subjects in the thiazide group had significantly greater odds of developing diabetes.

Is this a problem? The investigators state that the increase in DM did not result in a greater rate of adverse events compared to the other groups. Are they trying to sweep the issue under the rug? Or are they postulating that the diabetic state induced by thiazides is less malignant than naturally occuring DM? Adverse events data was only 2 years out – not long enough to show effects from new onset DM. The increased risk may have also been partially washed out by the increase in DM among all groups, and the lack of comparison with placebo. I’m not sure I would dismiss the risk as easily as they suggest – but I guess I dont have to worry about grant money…

With both beta-blockers and thiazides being linked to decreased glucose tolerance, the choice of anti-hypertensives is becoming much more complicated.

August 23, 2006

Even more uses for ACE-I’s

Filed under: cardiovascular, hypertension, lancet — medblog @ 7:14 am

Lancet 8/19 – Updated guidelines for Abdominal Aortic Aneurysm screening were put out by USPTF last year reccommending ultrasound in men aged 65-75 who have ever smoked, especially due to the mortality and lack of medical treatment options for the disease. Clearly endovascular pathology related to atheroma and smoking are somehow involved. with AAA.
Enter ACE-inhibitors, which seem to be showing evidence of vasoprotective effects through some modulation of the renin-angiotensin system – also thought to be involved somehow with vascular pathology.

Hackam et al. publish a retrospective observational study in the current Lancet, investigating the use of ACE-I’s in patients with AAA. They analyzed records of 15,000 patients hospitalised with a primary diagnosis of abdominal aortic aneurysm in Canada. The researchers found that patients receiving ACE inhibitors before admission were significantly less likely to present with aortic rupture.(Adjusted Odds Ratio: 0.83) They conclude that the beneficial effect of such drugs is independent from their antihypertensive properties, because use of other antihypertensive agents was not associated with a lower risk of AAA. Clearly the study comes with all of the shortcomings of a retrospective study, and although we cannot conclude a causal effect, RCTs are warranted.

April 22, 2006

Treating *Pre*-Hypertension with ARBs

Filed under: hypertension, NEJM — medblog @ 7:16 am

NEJM – As the benefits of normotension have become clear, the JNC guidlines defining high blood pressure have become more aggressive. The latest revision created a pre-hypertension category of increased risk, in order to stress preventetive measures.

With a high rate of pre-hypertensive patients progressing to hypertension, would medical treatment prevent this change? In the first major study to explore such an option, the latest New England published a article by Julius, et al. testing whether it was feasible to treat pre-hypertension with candesartan.

722 patients with pre-hypertension, tested over three weekly readings, were included in the study. The subjects were randomized to ARB (16mg of candesartan) or placebo. The placebo-control period was two years, followed by a 2 year phase in which all subjects recieved placebo.

During the treatment period 154 pts in the placebo group developed HTN, but only 53 in the candesartan group – a 66% reduction. After the treatment period was over, there was still a 15% risk reduction for the group that had been on the ARB.

Should treating pre-HTN with medication become standard treatment? This study seems to support that conclusion.

February 23, 2006

bathtime fun and killing VRE, CRP for HTN?

Archives 2/13 – Why didnt anyone think of this earlier? Apparently a study by Vernon, et al. cleaning ICU patients with Chlorhexidine cloths effectively lowers patient colonization and contamination of healthcare workers’ hands and hospital surfaces. The intervention does a much better job than soap and water, or cloths alone. Anything to keep me from having to wear those stupid isolation gowns….

In another article – apparently you cant use CRP to measure risk all things cardiovascular. Unlike in older adults, CRP is not associated with risk of incident hypertension in young adults when adjusted for BMI – not suprising considering the two are probably strongly related…. (more…)

February 1, 2006

Connecting GFR to Cardiovascular Outcomes: ALLHAT

Filed under: annals of internal medicine, cardiovascular, hypertension, renal — medblog @ 2:45 am

Annals 2/7 – Picking apart two frequently co-morbid diagnoses, Rahman et al. propose that low GFR is an independent predictor for CVD in hypertensive patients. In fact, patients with a moderate to severe reduction in GFR had a higher 6-year incidence of developing CHD than ESRD.

They also report that amlodipne is less effective than the diuretic chlorthalidone in preventing CHD, and lisinopril is less effective than chlorthalidone in preventing heart failure. (more…)

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