Clinicial Briefs

By Louis Kuritzky, MD

Weight Loss Intervention on Antihypertensive Medication

The hot study was a prospective randomized trial in hypertensive patients to determine if achieving diastolic blood pressures of 90, 85, or 80 were differentially associated with outcomes. One subgroup in this study population (n = 112) was selected on the basis of BMI more than 27 and were randomized to weight loss intervention, or control, in addition to the same stepwise antihypertensive therapy that all subjects received. Weight reduction intervention consisted of counseling by a registered dietitian, advice about food selection, and a diet of restricted calories with decreased fat intake. There were periodic contacts at least every 3-6 months throughout the study. Those in the control group were told that weight loss should be achieved, but received no further input in that regard.

At the six-month point, the intervention group had lost more weight than the control (approximately 1.4 kg), but at the 30-month point, no difference was seen.

The mean number of medications needed to achieve goal diastolic blood pressure was lower at the six-month point (2.9 vs 3.5 medications) for the intervention group than the control group; furthermore, this difference in medication requirement remained significantly lower for the duration of the 30 month trial, despite the regained weight in the intervention group, and despite the fact that at the end of the trial, there was no significant difference in weight loss between the groups. Jones and colleagues are unable to explain the persistent beneficial effect on blood pressure by an initial weight loss, but encourage renewed enthusiasm for early weight loss as a tool to potentially reduce the number of medications needed for blood pressure control, thus enhancing compliance, and reducing expense.

Jones DW, et al. Am J Hypertens 1999;12:1175-1180.

Clinicial Briefs

By Louis Kuritzky, MD

Urgent Colonoscopy

Although there have been case reports of successful evaluation and acute treatment of diverticular bleeding by urgent colonoscopy, there have been no studies to evaluate issues such as the complication or recurrent bleeding rate using this intervention. Urgent colonoscopy was defined as being performed 6-12 hours after hospitalization and within one hour of colonic sulfate purging (i.e., Golytely, Colyte). This report details experience from two separate studies.

In the first study (1986-1992), 17 of 73 diverticulosis patients with severe bleeding had diverticular hemorrhage as the etiology. In the second study (1994-1998), 10 of 48 patients had definite diverticular hemorrhage as the cause, 14 had presumptive diverticular hemmorhage, and 24 had incidental diverticulosis.

In the second study, all patients with definite diverticular hemorrhage received colonoscopic treatment, consisting of local epinephrine injection or local tamponade for actively bleeding vessels, and bipolar coagulation for nonbleeding visible vessels.

In the group treated medically without colonoscopic treatment (e.g., transfusions), bleeding, requiring hemicolectomy, did occur in six patients, of whom two sustained surgical complications. Endoscopic treatment did not result in any complications or recurrent bleeds, and none of the endoscopically treated patients required surgical intervention. Even during the long-term follow-up (18-49 months), only one patient, a patient with presumptive diverticular hemorrhage on warfarin, re-bled. Based upon these data, Jensen and colleagues suggest using surgical intervention only for those patients with definite or presumptive diverticular hemorrhage in whom medical or colonoscopic treatment has failed or produced complications.

Jensen DM, et al. N Engl J Med 2000;342:78-82.

Clinicial Briefs

By Louis Kuritzky, MD

Instability of Atherosclerotic Plaques

The major complications of atherosclerosis are apparently related to stability of atheromatous plaques, not just extent of atherosclerosis. Unstable angina, MI, stroke, and TIA have all been associated with irregular or ruptured plaques. Although local factors like sheer stress and plaque structure are felt to be important, systemic factors like autoimmunity and infection, resulting in plaque inflammation and hemorrhage, also appear to play a role.

One important issue evaluated in this study was the relationship between plaque-surface irregularity and MI in subjects of the European Carotid Surgery Trial (n = 3007) for persons with symptomatic carotid stenosis. Evaluations included comparisons of carotid angiograms (bilateral) and carotid pathology specimens for the subgroup which underwent carotid endarterectomy (n = 1671). There is no information in this trial about markers of infection or inflammation, such as CRP.

The risk of non-stroke vascular death (i.e., essentially coronary artery disease death) was significantly higher in persons with plaque surface irregularity (RR = 1.67). Additionally, persons with surface irregularity in one carotid were more likely to have the same in the contralateral artery. Jenson and colleagues comment that traditional risk factors (HTN, cholesterol, smoking, Diabetes) do not account for which persons will develop the demonstratedly higher risk irregular plaques.

Rothwell PM, et al. Lancet 2000; 355:19-24.