Cardiology

More important than the choice of pharmaceutical agent in the treatment of elderly hypertensive patients is the achievement of goal blood pressure. Low-dose diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers are equally effective in reducing cardiovascular end points. Most patients will require 2 or more drugs to achieve target blood pressure, and physicians should feel comfortable prescribing 3 to 4 agents to a significant proportion of patients.

Studies have shown that elderly patients with heart failure are undertreated with evidence-based therapy, such as angiotensin-converting enzyme inhibitors and beta-blockers, although these therapeutic options appear to be effective in this age group. The risk of some side effects may be increased in elderly patients, and physicians should be aware of those when prescribing therapy. Cardiac resynchronization therapy is predicted to play a major role in future heart failure treatment, including in the elderly population.

We performed a meta-analysis of the effect of long-term treatment with antiarrhythmic drugs for the prevention of recurrent atrial fibrillation after conversion to sinus rhythm. We found that several class IA, IC, and III drugs are effective in maintaining sinus rhythm, but virtually all of them increase adverse effects, including proarrhythmia. In addition, class IA drugs are associated with increased mortality. The final risk-benefit ratio of antiarrhythmic drugs on clinically relevant outcomes is still unclear.

Using a retrospective observational study design, we assessed whether all angiotensin-converting enzyme (ACE) inhibitors had similar mortality rates after acute myocardial infarction in patients aged 65 years or older. Our results showed that mortality rates for enalapril, fosinopril, captopril, and quinapril were higher than that for ramipril. This suggests that there is no class effect for ACE inhibitors. Further research is needed to confirm the results of our study.

Myths in medicine addresses two myths about smoking before surgery.

Can any physician consider using intermittent inotropic therapy in patients with congestive heart failure?

Cardiac resynchronization treatment (CRT) has moved into the mainstream of patient care after several randomized studies have demonstrated improved quality of life, reversed remodeling, and decreased heart failure hospitalizations. More recently, 2 large studies have demonstrated a mortality benefit of CRT independent of implantable cardioverter defibrillator

The vital cell stress protein, heat shock protein (Hsp)60, has recently been found in the circulation of healthy subjects over an extremely large concentration range. We performed an analysis of subjects with diabetes to determine whether Hsp60 is associated with biochemical markers of cardiovascular disease. Results showed that high circulating levels of Hsp60 are associated with clinically manifest cardiovascular disease. Hsp60 has cytokine-like actions, which may be responsible for this association.

Circulating biomarkers have been used in cardiovascular medicine as predictors of incident or prevalent disease.

We assessed whether duration of nonischemic cardiomyopathy was related to the degree of benefit from implantable cardioverter-defibrillator (ICD) insertion. Subjects who had a recent diagnosis of nonischemic cardiomyopathy had at least a similar benefit from ICD insertion as did those with a remote diagnosis. These results indicate that ICD therapy should be considered in such patients as soon as they are diagnosed and once reversible causes of left ventricular dysfunction have been excluded.

This review presents a substudy analysis of the Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) trial, which examined the role of prophylactic implantable cardioverter defibrillator (ICD) implantation in patients with nonischemic cardiomyopathy.

We assessed whether C-reactive protein (CRP) concentrations predicted future risk of hypertension in a cohort of young adults. Results showed that CRP levels do not independently predict risk of incident hypertension after accounting for body mass index. Further research is needed in the area of inflammation and hypertension, with a special focus on the effect of obesity and age-related changes on this process.

Is hypertension an inflammatory disease?

This study evaluated whether exogenous insulin use to control blood glucose in patients with type 2 diabetes was associated with the development of hypertension by analyzing data obtained from a large national sample in Taiwan. Exogenous insulin use was shown to be a significant risk factor for hypertension development.

Insulin resistance has been linked to an increased risk of hypertension, type 2 diabetes mellitus, and cardiovascular disease.

We assessed the histologic features of 526 carotid plaques from consecutive patients undergoing endarterectomy for symptomatic carotid stenosis and found a high prevalence of coronary-type plaque instability, with strong correlations between macrophage infiltration and both cap rupture and time since stroke. Temporal trends were much weaker after a transient ischemic attack than after a stroke, with a tendency for plaque features to persist for a longer period, suggesting heterogeneity in the underlying pathological mechanisms.

This is the largest study of excised carotid plaques to date. All patients were symptomatic. Although not all plaques could be analyzed for each category (which excluded 94 plaques from cap analysis), this remains the largest histological study of its kind.

Diabetic cardiomyopathy is a clinical condition characterized by altered myocardial function in the absence of coronary artery disease, hypertension, and valvular or congenital heart disease. Patients with this condition exhibit changes in cardiac structure that may be attributed to the direct effect of diabetes mellitus. The author discusses the mechanisms, risk factors, screening, diagnosis, prevention, and treatment of cardiomyopathy in patients with diabetes.

The increasing prevalence of atrial fibrillation in the elderly, especially compared with younger age groups, is striking (8% in persons > 80 years compared with 1% in those < 60 years).