Clinical Briefs

By Louis Kuritzky, MD

Increase in Blood Glucose Concentration During Antihypertensive Treatment as a Predictor of Myocardial Infarction

Release of the ALLHAT trial, the largest antihypertensive trial ever performed, has suggested that chlorthalidone, amlodipine, and lisinopril all provide favorable cardiovascular risk reduction. Additionally, this trial demonstrated that chlorthalidone, in addition to being less expensive, has a slightly more favorable cardiovascular risk reduction than its comparators. On the other hand, even modest doses of chlorthalidone were associated with an increase in glucose.

The Uppsala longitudinal study of men began in 1970-1974, and included 2322 men younger than age 50 at that time. In this population, Dunder and colleagues studied men (n = 1860) who were seen at baseline and 10 years later, and grouped them into participants who had or had not received antihypertensive treatment. Hypertensive treatments include beta blockers, thiazides, or both, with a small subset of individuals having been treated with hydralazine also. Subjects were evaluated for incidence of myocardial infarction, metabolic syndrome, and glucose derangements.

Subjects with an MI had a significantly higher fasting blood sugar than those who did not suffer an MI but only in the group receiving antihypertensive treatment. Whether the metabolic effect of antihypertensive therapy upon glucose mitigates some of the beneficial effects upon cardiovascular mortality remains uncertain, given the favorable results of studies like the ALLHAT trial.

Dunder K, et al. BMJ. 2003;326:681-684.

Adverse Drug Events in Ambulatory Care

Adverse events (AE) from medications have been well studied among hospital inpatients. It has been reported that as many as 6.5% of hospitalized patients have one or more AE, of which more than one-fourth are considered preventable. AE in the ambulatory setting have been less studied, but have been estimated to occur 5-35% of the time.

Gandhi and colleagues prospectively studied patients (n = 661) from Boston-area primary care practices. Any person older than age 18 who received a prescription was eligible. Telephone survey at 10, 14, and 90 days, chart review, and patient input were used to discern possible AE.

Twenty-five percent of patients experienced AE, of which approximately half were rated serious,’ including symptomatic bradycardia, symptomatic hypotension, and GI bleeding. Eleven percent of AE were considered preventable, and more than twice that number were "ameliorable" (ie, steps could have been taken to mitigate or reverse the AE). AE are common in the outpatient setting and offer substantial room for clinicians to obviate (or mitigate) burden to our patients.

Gandhi TK, et al. N Engl J Med. 2003;348:1556-1564.

Prevention of Hip Fracture by External Hip Protectors

In the year following a hip fracture (HIP), as many as one-third of persons die, and an equal number suffer inability to walk, or severe disability. One of the interventions intended to reduce HIP is use of external hip protectors (EHP), cushion-like devices worn during daily activity, which are intended to diminish the effect of a fall. Based upon the 10 randomized trials published to date, clinicians may be left with some degree of uncertainty concerning the efficacy of HIP, since 5 studies showed a statistically significant HIP impact, 2 studies found a favorable trend, and 3 studies showed no effect.

Van Schoor and associates enrolled 561 persons older than age 70 who resided in nursing homes or other assisted living facilities. Subjects wore hip protectors for approximately 15 months. Two different varieties of hip protector were used: the Safehip and the Tytex devices.

Time to first hip fracture did not differ between those who wore an EHP and the control group. Compliance (monitored by unannounced visit) with EHP was imperfect: 61% at 1 month, 45% at 6 months, and 37% at 1 year. Whether greater compliance with EHP might have altered the outcome is unknown, but Van Schoor et al also mention that protectors with greater impact-effectiveness are to be desired, since 4 of 18 fractures in the intervention group occurred while the subject was wearing the protective device.

Van Schoor NM, et al. JAMA. 2003;289:1957-1962.

Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.