Deborah S. Minor

Dietary supplements and hypertension: potential benefits and precautions.

J Clin Hypertens (Greenwich). 2012; 14:467–471. ©2012 Wiley Periodicals, Inc.

Chocolate--guilty pleasure or healthy supplement?

Dark chocolate and other cocoa products are popular in the population as a whole, but their overall health benefit remains controversial. Observations from the Kuna Indian population have shown an impressive cardiovascular health benefit from cocoa. For various reasons, this benefit has not been as robust as in other populations. Additionally, several mechanisms have been proposed that might confer cocoas possible health benefit, but no consensus has been reached on cocoas physiologic role in promoting cardiovascular health. Flavanols, as well as theobromine, may contribute to enhancements in endothelial function and subsequent improvements in various contributors to cardiovascular disease (CVD) including hypertension, platelet aggregation and adhesion, insulin resistance, and hypercholesterolemia. While the benefits of cocoa may be altered at the various stages of growth, development, and production, it appears that for many people “healthy” dark chocolate may, indeed, provide a pleasurable role in CVD risk reduction. The objectives of this review are to discuss the associations of cocoa with decreased blood pressure and improved CVD risk, to describe the possible mechanisms for these potential benefits, and to highlight considerations for the use of cocoa as a dietary supplement.

Improving Influenza Vaccination Rates by Targeting Individuals not Seeking Early Seasonal Vaccination

BACKGROUND Influenza morbidity and mortality remain high in the United States although vaccination clearly improves health outcomes and reduces health expenditures. This study was designed to assess the effectiveness of mail and telephone reminder strategies on improving existing clinic influenza vaccination rates among those not seeking early seasonal vaccination. METHODS In mid-November, we randomized 1371 patients at a hypertension clinic into 1 of 2 intervention groups, a mail reminder group (letter plus the Centers for Disease Control [CDC] Influenza Vaccine Information Statement) or a phone reminder group (same information via a personal phone call), or a control group. The following spring, records were reviewed for vaccination documentation. Patients without documentation were contacted by phone to identify whether vaccination for the current season had been obtained. RESULTS The final analysis included 884 patients (62% women, mean age 57.2 years old): 325 in the mail reminder group, 246 in the phone reminder group, and 313 represented the control group. Overall, 388 of these patients (44%) were vaccinated. Vaccination rates were significantly higher in the intervention groups, 46% for the mail reminder group (age and sex adjusted odds ratio [OR], 1.8, 95% confidence interval [CI], 1.3-2.5; P=.001) and 56% for the phone reminder group (OR, 2.8; 95% CI, 1.9-4.0; P<.0001), compared to 33% in the control group. Both interventions increased vaccination rates in all age/sex groups. CONCLUSION In contrast to earlier studies, this intervention occurred later in the influenza vaccination period excluding those who seek early vaccination and allowing interventions to target those less likely to receive vaccination. Compared to previous studies demonstrating only trivial or modest benefits, both mail and phone reminders effectively increased clinic vaccination rates in our group of patients.

Evaluation of Blood Pressure Measurement and Agreement in an Academic Health Sciences Center

J Clin Hypertens (Greenwich). 2012;14:222–227. ©2012 Wiley Periodicals, Inc.

DPP-4 inhibitors and angioedema: a cause for concern?

INTRODUCTION Medications are frequently associated with angioedema, a leading cause of hospitalizations for hypersensitivity reactions in the United States.1 Antihypertensives, likely angiotensin-converting enzyme inhibitors (ACEI), are the most commonly identified class, accounting for approximately 1 in 4 of these hospitalizations.1 A progressive rise has been noted in the prevalence of ACEI-associated angioedema, which is most likely a consequence of increased utilization. Dipeptidyl peptidase IV inhibitors (DPP-4I) are often used concurrently with ACEI, and this combination may increase the potential for development of angioedema. A new class of medications, the DPP-4I, was introduced to the United States market in 2006 for the management of type 2 diabetes. This class has interesting physiologic effects and mechanisms that also may increase the possibility of hypersensitivity reactions. Sitagliptin (Januvia) was the first medication approved, followed in 2009 by saxagliptin (Onglyza). In 2007, postmarketing reports of hypersensitivity reactions with sitagliptin, including angioedema, prompted warnings and labeling changes.2 The labeling for saxagliptin also reports hypersensitivity reactions that occurred in pre-approval clinical trials.3 The most recent treatment algorithm published by the American College of Endocrinology promotes the use of DPP-4I as a first-line option for management of type 2 diabetes mellitus (DM).4 This recommendation will likely result in increased utilization of this class of medications, which may potentially lead to increased reports of hypersensitivity reactions. With hypertension (HTN) as a common comorbidity of DM, many patients will likely be managed with both ACEI and DPP-4I. Thus, in DM patients with HTN who develop angioedema, there may be significant potential for incorrectly attributing the reaction solely to ACEI or angiotensin receptor blocker (ARB) therapy. Currently, few data are available to confirm the clinical impact and associations of DPP-4I and angioedema, including any additive or synergistic angioedema risk in patients taking both ACEI/ ARB and DPP-4I.

β‐Blockers and Chronic Obstructive Pulmonary Disease: Inappropriate Avoidance?

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States and is often accompanied by one or more comorbid conditions. While there are established morbidity and mortality benefits of β‐blocker (BB) use for certain cardiovascular conditions, data suggest that clinicians are often reluctant to prescribe them in the presence of COPD because of concerns for bronchoconstriction, despite evidence that they are typically well‐tolerated among these patients. Treatment guidelines for COPD are consistent with those for cardiovascular disease management and support the role of BBs in management of particular cardiovascular conditions, even in the presence of severe COPD. Adherence to these guidelines could result in significant decreases in morbidity and mortality among patients with COPD. Additionally, current treatments for COPD are often linked to increased cardiovascular disease events. Further study is needed to clarify and guide therapeutic management in patients with COPD.

Determinants of pulse pressure and annual rates of change in the Atherosclerosis Risk in Communities study.

Introduction: The aim of this study was to examine the effect of vascular and lifestyle risk factors on the annual rate of change in pulse pressure (PP) in a biracial, middle-aged cohort. Methods and results: The study population, drawn from the Atherosclerosis Risk in Communities (ARIC) cohort, included 10 071 participants, aged 45–64 years at baseline, with a complete set of SBP and DBP readings at each of four visits 3 years apart. The average annual increase in PP was 1.23 mmHg [standard error (SE 0.01], after adjusting for baseline age differences. Compared with white men, African-American women had the highest rate of annual increase in PP (0.41 (SE 0.05) mmHg/year greater) followed by white women [0.23 (SE 0.03) mmHg/year greater] and African-American men [0.19 (SE 0.06) mmHg/year greater]. Conclusion: There were significant differences in both average baseline PP and average annual rate of change in PP between men and women and African-Americans and whites. Diabetes and obesity had the strongest effect on the absolute value of baseline PP and the annual rate of change in PP.

Rhabdomyolysis Associated With the Use of a Mislabeled “Acai Berry” Dietary Supplement

Introduction:This case report describes a patient who developed rhabdomyolysis temporally associated with the use of a mislabeled acai berry dietary supplement. Methods and Results.The authors describe a 22-year-old man presenting with rhabdomyolysis approximately 2 weeks after starting a weight-loss dietary supplement. His medical history was significant only for hypertension treated with amlodipine. The diagnosis of rhabdomyolysis was confirmed (creatine kinase, 84,000 IU/L, positive urine myoglobin) with other potential causes ruled out. The signs and symptoms of the patient gradually resolved and he was discharged on hospital day 5. Assessment using the Naranjo Adverse Drug Reaction Probability Scale yielded a score of 3, indicating a possible relationship between the supplement and rhabdomyolysis. Although the product was labeled and promoted as containing acai berry and additional ingredients, there was no acai berry found on analysis. Conclusion:Clinicians should be aware that all dietary supplements may vary in uniformity and contain unknown contaminants.