Clinical Briefs By Louis Kuritzky, MD
Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker’s bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Are NSAIDs Different in the CHF Impact?
Traditional NSAIDs have the potential to cause fluid retention and BP elevations, either of which can worsen heart failure (CHF). Coxibs, such as celecoxib and rofecoxib, have recently come under close scrutiny due to increased cardiovascular risk associated with their use, though not specifically increased CHF risk. Whether there might be a difference in impact upon CHF outcomes for persons who receive celecoxib or rofecoxib vs non-selective NSAIDs has not been widely studied, although an earlier trial indicated that receipt of a coxib prescription at discharge for CHF incurred an increase risk of rehospitalization in the next year compared to not receiving such treatment.
Hudson et al used a hospital database of discharge summaries in Quebec, Canada which included 2,256 persons aged 66 or older with CHF who had been prescribed an NSAID, celecoxib, or rofecoxib. The primary end point of the study was the risk of death and recurrent CHF. Comparing NSAIDs, rofecoxib, and celecoxib, the risk of CHF for celecoxib and traditional NSAIDs was no different. However, the hazard ratio for the primary end point was 1.27 for persons receiving rofecoxib vs celecoxib. Similarly, the hazard ratio for mortality was 1.44 for rofecoxib vs celecoxib. These data suggest that celecoxib is safer in persons with CHF than rofecoxib. Newer coxibs are being developed, and differences amongst them may be highly relevant.
Hudson M, et al. BMJ. 2005;330:1370.
Treatment of HTN and Cognitive Function: SCOPE
The study on cognition and prognosis in the Elderly (SCOPE) trial was comprised of adults aged 70-89 years (n = 4,937) with mild-to-moderate hypertension (HTN). Patient inclusion criteria for this double-blind, randomized, placebo-controlled trial also entailed cognitive function testing with the Mini Mental State Examination (MMSE). Persons with mildly reduced cognitive function have been shown to have greater risk for development of frank dementia. Whether treatment of HTN in persons with mild cognitive impairment might reduce the development of further cognitive decline is not well established.
SCOPE study subjects were treated with candesartan (CAN) or placebo for HTN. In the placebo group as well as the CAN treatment group, subjects were allowed open-label treatment with antihypertensives to control BP to a level of < 160/90, initially with HCTZ 12.5 mg/d. Subjects were subgrouped by mental status scores into high cognitive function (MMSE Score ≥ 27/30) versus lower cognitive function (MMSE = 24-27/30).
After a mean of 3.7 years treatment, the incidence of frank dementia was higher in persons who had entered the trial with lower cognitive function at baseline. However, decline in cognitive function in this group was less amongst those treated with CAN than placebo (P = 0.04). As has been seen in other trials, CAN treatment reduced non-fatal stroke (28%).
These data are encouraging that in addition to reducing macrovascular end points, CAN treatment of HTN in persons with mildly impaired cognitive function may reduce further cognitive function decline.
Skoog I, et al. Am J Hypertens. 2005;18:1052-1059.
Impact of Job and Marital Strain on BP
A high level of job stress (JOB) has been linked both to increased frequency of hypertension (HTN) and worsened cardiovascular outcome. Marital stress has also been associated with impact upon both daytime and nighttime BP, as measured by 24-hr ambulatory BP (ABPM).
Study subjects (n = 248) were normotensive, predominantly white Canadian adult men and women (age, 40-65) without evidence of CAD, diabetes, or kidney disease at enrollment. Job diversity included clerical, technical, nurses, and physicians. Subjects were in established relationships and employed full time. Marital strain was measured by the Dyadic Adjustment Scale; job strain was measured using the Job Content Questionnaire. Both are validated stress scales. All subjects underwent ABPM on a 'typical’ work day.
By multiple regression analysis, job strain and marital strain independently were both statistically significant variables for higher BP. The combination of job strain and marital strain were synergistic in their association with higher BP impact. Encouragingly, lower marital strain was associated with a mollifying effect upon JOB-induced BP elevation.
Tobe SW, et al. Am J Hypertens. 2005;18:1046-1051.
Are NSAIDs Different in the CHF Impact?; Treatment of HTN and Cognitive Function: SCOPE; Impact of Job and Marital Strain on BPSubscribe Now for Access
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