Adrian Messerli

Evaluation and Treatment of Patients With Systemic Hypertension

A 65-year-old man presented for evaluation of high blood pressure found on screening at a local health fair. History and physical examination did not show any signs or symptoms suggestive of a secondary cause, nor was there evidence of target end-organ damage except for grade 1 Keith-Wagener-Barker retinopathy. The patient denied taking any prescription or over-the-counter medications. Hypertension is the most common disease-specific reason Americans visit a physician. Despite the risks associated with an elevated blood pressure (BP), there is still woefully low achievement of recommended BP goals. From 1991 to 1994, only 27.4% of hypertensive Americans aged 18 to 74 years had a BP <140/90 mm Hg, the current stated goal for most people with hypertension, and in those with diabetes, less than half that number (11%) were controlled to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure VI (JNC VI) recommended goal of <130/85 mm Hg.1 The present update will provide an overview of the evaluation and management of essential hypertension and help to guide clinicians in developing a management plan for a patient like the one described above. Taking a proper BP is an important first step in the diagnosis of hypertension.2 Using the proper cuff size with patients resting quietly and comfortably (with back support if seated) for at least 5 minutes before measurement, 2 or more readings separated by 2 minutes should be taken and averaged. Initial elevated BP readings should be confirmed on at least 2 subsequent visits over a period of 1 week or more. A value that is consistently ≥140/90 mm Hg is diagnostic in healthy patients; a value >130/80 mm Hg should be used for those with diabetes or kidney disease and proteinuria. Initial evaluation of the hypertensive patient focuses on the presence …

Age, Blood Pressure Targets, and Guidelines: Rift Between Those Who Preach, Those Who Teach, and Those Who Treat?

That blood pressure (BP) increases with age has been known for almost a century. To what extent this increase in BP is physiological continues to be debated. The observation that in some isolated populations there is little if any BP slope with age is often taken as an argument that any increase in BP should be considered pathological. Conversely, once upon a time, textbook wisdom (those who taught) such as “the elevation of blood pressure may be a natural response to guarantee a more normal circulation to the heart, brain and kidneys”1 or “the hypertension might be a compensatory mechanism that should not be tampered with”2 has continued to spook physicians until this very day and seemed to attest to the “essentiality” of essential hypertension. This concept also instigated fear that, in susceptible patients, BP could be lowered too much. The thorough meta-analysis by Lewington et al3 alleviated these concerns by concluding that “usual BP is strongly and directly related to vascular (and overall) mortality without any evidence of a threshold down to at least 115/75 mm Hg.” However, closer scrutiny documents BP to gradually become a less powerful risk factor with age. At ages 40 to 49 years, a 20–mm Hg lower systolic …

Comparison of Outcomes in Patients Having Acute Myocardial Infarction With Versus Without Sickle-Cell Anemia

Sickle-cell disease (SCD) affects millions worldwide. Sickle-cell anemia (SCA), the most severe form of this disease, is the most common inherited blood disorder in the United States. There are limited data on the incidence, clinical characteristics, and outcomes of acute myocardial infarction (AMI) in these patients. Using data from the National Inpatient Sample database, we matched cases (AMI with SCA) with controls (AMI without SCA) in a 1:1 ratio for age, gender, race, and year of admission. We compared both groups in terms of clinical characteristics and inpatient outcomes and performed a logistic regression with mortality as the primary outcome. Using weighted samples, we also described trends of SCA in the general population of patients with AMI. Of the 2,386,657 admissions with AMI, SCA was reported in 501 (0.02%) patients, and 495 were successfully matched to controls. Patients with SCA were less likely to have risk factors for coronary artery disease than those without SCA. Patients with SCA were more likely to develop pneumonia, respiratory failure, and acute renal failure, and require mechanical ventilation, hemodialysis for acute renal failure and blood transfusion. In-hospital mortality was significantly higher in patients with SCA. In a multivariate analysis, SCA was an independent predictor of mortality (odds ratio 3.49; 95% confidence interval 1.99 to 6.12; p = < .001). In conclusion, myocardial infarction occurs in patients with SCA at a relatively early age. These patients do not typically have the traditional risk factors for the acute coronary syndrome. Mortality in these patients is significantly higher in age-, gender-, and race-matched controls.

In-hospital outcomes of percutaneous ventricular assist devices versus intra-aortic balloon pumps in non-ischemia related cardiogenic shock

Introduction: This study compared inpatient outcomes related to the use of these two devices among patients who developed cardiogenic shock not due to acute myocardial infarction or coronary revascularization. Methods: We extracted admission‐level records of patients with a diagnosis of cardiogenic shock who underwent either PVAD or IABP implantation from the National Inpatient Sample (NIS) database from 2010 to 2014. Our outcomes of interest were mortality and length of stay. Results: Inpatient mortality was significantly higher in the PVAD cohort. In multivariate analysis, PVAD use in these patients was associated with higher mortality. There was no difference in the length of stay between both groups among patients that survived to discharge. Conclusion: In our analysis of the NIS database, the use of PVADs in patients with cardiogenic shock of non‐ischemic origin was associated with higher mortality when compared to IABP use.

Sex differences in the contemporary management of HIV patients admitted for acute myocardial infarction

Studies have reported sex differences in the management of patients with acute myocardial infarction (AMI) in the general population. This observational study is designed to evaluate whether sex differences exist in the contemporary management of human immunodeficiency virus (HIV) patients admitted for diagnosis of AMI.

Temporal trends, characteristics and outcomes of fibrinolytic therapy for ST-elevation myocardial infarction among patients 80 years or older: Temporal trends, characteristics and outcomes of fibrinolytic therapy for ST-elevation myocardial infarction among patients 80 years or older

Pharmacologic reperfusion therapy is a recommended and effective strategy in patients with ST‐elevation myocardial infarction (STEMI) when percutaneous coronary intervention (PCI) is not available. This study investigates temporal trends and outcomes of fibrinolytic therapy (FT) in elderly patients with STEMI.

Impact of Diabetes Mellitus on Percutaneous Coronary Intervention Outcomes: Real-World Lessons From a Large Chinese Single-Center Registry

The mortality of coronary artery disease (CAD) in the Chinese population is historically low compared with Western levels, but the burden has been increasing. Coronary artery disease is now the major cause of death for both men and women in China. This is in part due to an aging population, but more importantly due to an increasing incidence of traditional risk factors. Over 60% of Chinese men are current smokers, and relevant to this, China is the largest tobacco producer and consumer in the world. In addition, hypertensive heart disease, diabetes mellitus (DM), hyperlipidemia, obesity, and air pollution have all reached epidemic proportions. As a consequence, in 2008, the death rates (per 100 000 population) for cardiovascular (CV) diseases in China actually exceeded those in the United States. The first cardiac intervention in China, a percutaneous transluminal coronary angioplasty (PTCA), was carried out in 1984. In the following 2 decades, adoption was slow; a total of only 8000 patients underwent PTCA in 1999. In 2001, emergency percutaneous coronary intervention (PCI) was performed in only 2820 patients, an impressively insignificant number given a total population of over 1.2 billion at that time. However, use of cardiac catheterization and PCI has grown tremendously over the past 2 decades, especially in urban Chinese cities. Between 2001 and 2011, coronary catheterizations grew from 26 570 cases per annum to 452 784, a 17-fold increase. Annual PCI hospitalizations soared 21-fold from 9678 to 208 954. Moreover, Chinese cardiologists have been quick to adopt new practices; the use of the radial approach increased from 3.5% to 79% and of drug-eluting stent (DES) from 18% to 97%. Due to the absence of a nationwide standard disease registration and classification system in China, precise information does not exist regarding the number of events or deaths from CAD for the entire country. Although new technology has been increasingly applied, there are significant differences between Chinese CAD clinical practice, recommended guidelines, clinical outcomes, and the usage patterns of PCI. Data on PCI quality and outcomes have also been lacking. In addition, a specific association of problems with DM has increasingly been noted. In a very recent retrospective study, Jiang et al presented data on apparent type 2 DM patients who were diagnosed by the following: an abnormal blood glucose level ( 126 mg/dL) after an overnight fast, an abnormal glycosylated hemoglobin test ( 6.5%), or an abnormal glucose tolerance test (2 hours, 200 mg/dL). These patients type 2 DM were considered to have a disease predictive of adverse events after implantation of a DES. In a meta-analysis by Zheng et al, it was found that increased blood levels of Hemoglobin A1c were associated with increased major adverse cardiovascular events (MACEs) in patients with type 2 DM (these patients in the meta-analysis meet the criteria for type 2 DM as defined by the authors) following PCI. Wang et al report an analysis of the impact of type 2 DM (type 2 DM criteria met by age) on a large cohort of patients (n 1⁄410 724) who underwent PCI at a single high-volume center in China. Such articles which involve a large Chinese patient base are extremely important and many of the results are discussed subsequently in this editorial. Although the manuscript of Wang et al has important limitations, it is still possible to glean valuable observations. Also worthy of comment regarding the Chinese population is the increased incidence of cytochrome P450 C19 (CYP2C19) reduced function (also referred to as loss-of-function) polymorphisms in Asians and in Chinese, which can increase CAD risk. The reduced function alleles of CYP2C19 polymorphism, especially the CYP2C19*2 allele, are associated with a decreased effect of clopidogrel (from a decreased conversion of clopidogrel to its active moiety), with a resultant increase in MACE following PCI in clopidogrel-treated patients. These reduced function alleles have a significantly increased prevalence in Chinese patients and this must be taken into account in comparing PCI results, especially since clopidogrel safety is essentially the same when comparing races.

Characteristics, Management, and Results of Out-of-Hospital Cardiac Arrest (OHCA) With or Without ST-Segment Elevation Myocardial Infarction (STEMI):

Out-of-hospital cardiac arrest (OHCA) continues to be a major public health issue and leading cause of death. Cardiac arrest, also known as cardiopulmonary arrest or sudden death, is defined by the American Heart Association as the “cessation of cardiac mechanical activity, as confirmed by the absence of signs of circulation.” The etiology of cardiac arrest has been defined using the Utstein classification system, which includes 6 primary causes. The first is defined as medical, where the cause is presumed to be due to a cardiac or other medical cause. Additional primary etiologies include trauma, drug overdose, drowning, and asphyxia. The major causes of sudden cardiac death include advanced coronary artery disease and heart failure, both leading to lethal arrhythmias including but not limited to ventricular tachycardia and/or fibrillation. Sudden cardiac death in the United States has an incidence of nearly 300 000 annually and a worldwide incidence of over 4 million annually, highlighting the importance of research in this area. In the article by Arabi et al entitled “Clinical Profile, Management, and Outcome in Patients with Out of Hospital Cardiac Arrest (OHCA) and ST Segment Elevation Myocardial Infarction: Insights from a 20-year Registry,” the authors describe the survival trends including management and outcomes of patients admitted following OHCA with ST-segment elevation myocardial infarction (STEMI) or without STEMI. This is the first study that provides population-based information in the previously underrepresented middle eastern population. The data were obtained from analysis of a 20-year-registry of patients admitted to a cardiac tertiary care facility in Qatar and included 987 patients. Of those admitted following OHCA, 30% were diagnosed with a STEMI. In those diagnosed with STEMI, thrombolytic therapy was used in 38% and coronary angiography was performed in 22%. Of those undergoing angiography, 16% received percutaneous coronary intervention (PCI) during admission. The use of PCI increased significantly during the last 5 years of the study and is a likely factor in the observed decrease in the in-hospital mortality of patients with STEMI during that period of the study. The Role of Cardiac Catheterization in OHCA

Trends in the Incidence and In-Hospital Outcomes of Patients With Atrial Fibrillation Complicated by Non-ST-Segment Elevation Myocardial Infarction

Atrial fibrillation (AF) can present with non-ST-segment elevation myocardial infarction (NSTEMI). The incidence, characteristics, outcomes, and treatment of this subgroup of patients with AF remains poorly studied. Using data from the National Inpatient Sample database, we (1) compared baseline characteristics of patients with AF with/without NSTEMI, (2) evaluated their outcomes and associated trends over the study period (2004-2013), and (3) evaluated revascularization (by percutaneous coronary intervention or coronary artery bypass graft [CABG]) and the impact on patient outcomes. Of the 3 923 436 patients admitted with a primary diagnosis of AF, 47 785 (1.2%) had a secondary diagnosis of NSTEMI. In this subgroup with AF and NSTEMI, there was a significant trend toward a decrease in mortality (P = .002), stroke (P < .001), and gastrointestinal bleeding (P < .001) during the study period. Compared to unrevascularized patients, revascularized patients were more likely to be younger (72.2 ± 10.2 vs 77.0 ± 11.8 years old, P < .001), male (57.8 vs 42.7%, P < .001), and had a much higher incidence of coronary risk factors. Revascularization was associated with increased survival in multivariable analysis (odds ratio: 0.562, 95% confidence interval: 0.334-0.946, P = .03). In conclusion, among patients admitted with AF, 1.2% were diagnosed with NSTEMI. A minority of patients with AF and NSTEMI underwent revascularization and had better in-hospital outcomes.

Relation of CHA2DS2VASC Score with Hemorrhagic Stroke and Mortality in Patients Undergoing Fibrinolytic Therapy for ST Elevation Myocardial Infarction

Hemorrhagic stroke (HS) is a feared complication of Fibrinolytic therapy (FT). Risk assessment scores may help in risk stratification to reduce this complication. Patients (admissions) ≥18 years with a primary diagnosis of ST-elevation myocardial infarction (STEMI) who received systemic thrombolysis were extracted from Nationwide Inpatient Sample database and stratified and compared based on CHA2DS2VASC score 0 to 3, 4 to 6, and 7 to 9 as low, intermediate and high risk, respectively. The primary outcomes of interest were HS and mortality. We performed logistic regression analysis with a composite of HS and mortality as the primary end point. Of the 917,307 admissions with a primary diagnosis of STEMI, 39,579 (4.3%) underwent FT. The median score was 3 (interquartile range 1 to 5). The rate of HS significantly increased in the risk category compared with the low and intermediate groups (0.5% and 0.6% vs 4.1%; p <0.001). Mortality increased with increasing risk category (3.8% vs 10.5% vs 20.7%; p <0.001). Compared with the low-risk group patients in the intermediate (odds ratio 2.11 95% confidence interval [CI] 1.56 to 2.85; p <0.001) and high risk groups (odds ratio 3.47 95% CI 1.68 to 7.2; p <0.001) were more likely to experience the composite end point of HS or inpatient mortality. CHA2DS2VASC score performed better at predicting mortality (area under curve 0.67, 95% CI 0.64 to 0.7; p = 0.014) than HS (area under curve 0.6 95% CI 0.52 to 0.69; p = 0.021). In conclusion, patients with high CHA2DS2VASC score (7 to 9) are at a higher risk of hemorrhagic stroke and death after FT for STEMI. CHA2DS2VASC score performed better at predicting mortality than hemorrhagic stroke in this cohort.