Clinical Briefs

By Louis Kuritzky, MD

Effects of Long-Term Treatment With ACE Inhibitors in the Presence or Absence of Aspirin

Both angiotensin converting enzyme inhibitors (ACEI) and aspirin (ASA) have a proven valuable track record in a variety of cardiovascular preventive and therapeutic areas. One of the mechanisms by which ACEI are believed to confer benefit is the production of vasodilatory prostaglandins, including PGI-2 and PGE-3. Since ASA can blunt production of prostaglandins, it is conceivable that the combination of the 2 might "cancel out" beneficial effects. To date, evaluation of large clinical trials in which both ASA and ACEI were used have provided conflicting data. Hence, Teo and associates undertook a systematic review of long-term randomized trials in which ACEI and ASA were coadministered (n = 22,060) for meta-analysis.

ACEI treatment in these trials (including the SOLVD treatment, SOLVD prevention, SAVE, AIRE, TRACE, and HOPE studies) produced overall a 22% reduction in major clinical outcomes. Concomitant use of ASA was not associated with a statistically significant diminution of benefit. Based upon this information, Teo et al suggest that for persons who are receiving either ACEI or ASA, if the other agent is indicated, clinicians may feel confident that the combination will not reduce beneficial effects.

Teo Koon K, et al. Lancet. 2002;360: 1037-1043.

Long-Term Risks Associated with Atrial Fibrillation: 20-Year Follow-up of the Renfrew/Paisley Study

Most of the studies of atrial fibrillation (AF) that address cardiovascular (CV) consequences provide only short-term or intermediate-term insight (6 months-24 months). Long-term consequences of AF are much less studied. Simon and colleagues evaluated CV outcomes (including hospitalizations and deaths) over a 20-year follow-up in 15,000 persons enrolled in Renfrew and Paisley, Scotland. The population was middle-aged (45-64 years) at enrollment.

At entry enrollment (1972-1976), 100 persons had AF. During the extended follow-up, women manifest a 5-fold increase in cardiovascular hospitalization or death, and risk in men was 2-fold increased. Lone AF (AF in the absence of discernible cardiovascular disease) did not confer a statistically significant increase in cardiovascular risk. The increase in CV risk associated with AF was expressed primarily as stroke and heart failure. This new information indicates substantial long-term risk from AF. Simon and colleagues suggest that strategies to prevent CHF, as well as those already commonly practiced for stroke prevention, may be of benefit in persons with AF.

Simon S, et al. Am J Med. 2002;113: 359-364.

Olfactory Impairment in Older Adults

Despite widespread attention to the demographics and management of hearing and visual impairments in older adults, there has been little study of olfactory impairments (OLF). Olfactory impairment can results in aggravation of nutritional problems, inability to respond promptly to risk situations such as fire or gas leaks, and reduce quality of life. To better determine the prevalence of OLF, Murphy and colleagues examined data from participants in the Epidemiology of Hearing Loss Study (n = 2491), a cross-sectional study of adults aged 53-97.

Initially, self-report of OLF was assessed by asking the question, "Do you have a normal sense of smell (compared to other people)?" Then, testing for OLF was performed using the San Diego Odor Identification Test (SDOIT), which uses natural home odors such as coffee and chocolate. OLF was defined as inability to identify at least 6 of 8 odorants.

One fourth of the tested population manifested OLF by SDOIT. On the other hand, only 9.5% of the population self-reported deficits in smell. A multiple logistic regression model determined that smoking, nasal congestion, stroke history, and epilepsy were associated with increased risk of OLF.

Murphy C, et al. JAMA. 2002;288:2307-2312.

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