domingo, 30 de junio de 2013

New European hypertension guidelines released: Goal is less than 140 mm Hg for all

Milan, Italy - The European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) published new guidelines today for the management of hypertension, simplifying treatment decisions for physicians with the recommendation that all patients be treated to <140 a="" blood="" hg="" href="" mm="" pressure="" systolic="">1
The new guidelines do make exceptions for special populations, such as those with diabetes and the elderly. For those with diabetes, the ESH/ESC writing committee recommend that physicians treat patients to <85 blood="" diastolic="" hg="" mm="" p="" pressure.="">
In patients younger than 80 years old, the systolic blood-pressure target should be 140 to 150 mm Hg, but physicians can go lower than 140 mm Hg if the patient is fit and healthy. The same advice applies to octogenarians, although physicians should also factor in the patient's mental capacity in addition to physical heath if targeting to less than 140 mm Hg.
On the whole, Dr Giuseppe Mancia (University of Milano-Bicocca, Milan, Italy), cochair of the ESH/ESC writing committee, said there is a shift toward "greater conservatism" with regard to drug treatment in the new guidelines. That said, the guidelines explicitly state physicians make decisions on treatment strategies based on the patient's overall level of cardiovascular risk.
Mancia said the guidelines are not prescriptive, or orders, but rather suggestions for practicing physicians. While there are some aspects of care that remain the domain of expert opinion, he said there is "no question that blood pressures exceeding 140/90 mm Hg increase the risk of cardiovascular disease and stroke," and these are both associated with a massive worldwide socioeconomic cost. Mancia added that 60% of patients remain disabled at one year following a stroke.

Tea and coffee lower blood pressure in large French registry

Milan, Italy - A large French retrospective analysis provides good news for caffeine lovers: investigators showed that drinking tea or coffee was associated with a small but statistically significant reduction in systolic and diastolic blood pressure. In addition, drinking tea and coffee was also associated with a significant reduction in pulse pressure and heart rate, although the heart-rate reductions were greater with tea.

Presenting the results at the European Society of Hypertension (ESH) 2013 Scientific Sessions, Dr Bruno Pannier (Centre d'Investigations Préventives et Cliniques, Paris, France) said that other studies have suggested a relationship between coffee and tea consumption and blood pressure, but these analyses haven't been conclusive. Some have suggested a benefit, while others found no relationship between tea/coffee consumption and blood pressure.
Presenting the data on 176 437 subjects aged 16 to 95 years of age who had a checkup at their center between 2001 and 2011, Pannier explained that the analysis was simply based on a questionnaire asking participants how much coffee or tea they drank per day. Individuals were classified into three groups: those who drank no coffee/tea, those who drank one to four cups, and those who drank more than four cups.
Overall, coffee is consumed more frequently than tea, although there were differences between the sexes, said Pannier. Men were more likely to drink coffee, while women were more commonly tea drinkers. Coffee consumption was also significantly associated with tobacco consumption, higher cholesterol levels, and higher scores on stress and depression indexes. Tea consumption, on the other hand, was associated with lower cholesterol levels but similarly high scores on the stress and depression measurements.
After adjustments that included these and other potential confounding variables, both coffee and tea consumption was associated with a significant reduction in systolic and diastolic blood pressure, as well as other variables.
Blood pressure among coffee drinkers

Variable None 1 to 4 cups >4 cups p (for trend)
Systolic blood pressure (mm Hg) 127.9126.7125.5<0 .0001="" br="">
Diastolic blood pressure (mm Hg)
Pulse pressure (mm Hg) 51.950.749.8<0 .0001="" br="">
Heart rate (beats/min) 63.262.963.20.001

Blood pressure among tea drinkers

Variable None 1 to 4 cups >4 cups p (for trend)
Systolic blood pressure (mm Hg) 127.3126.3125.3<0 .0001="" br="">
Diastolic blood pressure (mm Hg) 76.275.675.0<0 .0001="" br="">
Pulse pressure (mmHg) 51.150.750.3<0 .0001="" br="">
Heart rate (beats/min) 63.562.762.0<0 .0001="" br="">

Speaking during the session, Pannier explained that the group did not differentiate between green, black, or herbal tea consumption, which is one of the limitations of the analysis. In addition, the questionnaire is not sophisticated enough to address estimates in the caffeine content of the coffee consumed in France.
That said, Pannier believes that tea is a major source of flavonoids in the diet, and these compounds can improve vasodilation. "The vasorelaxing compounds included in these beverages might be involved in these results, something that has been suggested by the experimental data," he said.

Triple therapy for new-onset diabetes: A paradigm shift?

Chicago, IL - A novel approach of starting newly diagnosed type 2 diabetes patients on three therapeutic agents simultaneously showed greater and more durable reductions in HbA1c, less hypoglycemia, and less weight gain compared with conventional, stepwise add-on treatment in a new study reported yesterday here at the American Diabetes Association (ADA) 2013 Scientific Sessions [1].

The results of this so-called "triple therapy," in this case metformin, pioglitazone, and the glucagonlike peptide-1 (GLP-1) agonist exenatide (Byetta, AstraZeneca/Bristol-Myers Squibb Alliance), were hailed as potentially revolutionary and possibly "paradigm shifting," although questions remain.
The comparator stepwise add-on regimen was with metformin, a sulfonylurea (glyburide), and basal insulin glargine.

jueves, 27 de junio de 2013

EMA committee concludes diclofenac poses similar risks as COX-2 inhibitors

June 14, 2013 Michael O'Riordan

Michael O'Riordan Senior Journalist

London, UK - The Pharmacovigilance Risk Assessment Committee (PRAC) of the European Medicines Agency (EMA) has completed its review of diclofenac and concluded that the drug poses similar risks as selective COX-2 inhibitors, particularly when used in high doses (150 mg) or when used long term [1].

Still, committee says the benefits of diclofenac exceed the risks and that physicians should take the same precautions to minimize thromboembolic events as they do with patients treated with selective COX-2 inhibitors.
"Patients who have serious underlying heart or circulatory conditions, such as heart failure, heart disease, circulatory problems, or a previous heart attack or stroke, should not use diclofenac," according to PRAC. "Patients with certain cardiovascular risk factors (such as high blood pressure, raised blood cholesterol, diabetes, or smoking) should only use diclofenac after careful consideration. Healthcare professionals will also be advised to periodically reassess the need for patients to continue taking the medicine."

The review conducted by PRAC was launched in October 2012 after the EMA completed a report on published information assessing the cardiovascular safety of nonsteroidal anti-inflammatory drugs (NSAIDs). Like PRAC, the EMA concluded that there was a consistent but small increase in the risk of cardiovascular side effects with diclofenac compared with other NSAIDs and that this risk was on par with that observed with COX-2 inhibitors.

The current PRAC conclusions are based on all published and unpublished data. Its recommendations will now be forwarded to the Coordination Group for Mutual Recognition and Decentralized Procedures—Human (CMDh), a regulatory body representing member European Union states, which will adopt a final position.

Jun 14, 2013 17:30 EDT Source

1.European Medicines Agency. PRAC recommends the same cardiovascular precautions for diclofenac as for selective COX-2 inhibitors [press release]. June 14, 2013. Available here.

Artículo original:

miércoles, 12 de junio de 2013

ACP Releases New Guidelines for In-Hospital Hyperglycemia

The American College of Physicians (ACP) has revised the target blood glucose level for hospitalized patients, stating that doctors should aim for 140 to 200 mg/dL rather than trying to get to normoglycemia — a value of around 80 to 110 mg/dL. The greatest care should be taken among those in intensive care, who should not be given intensive insulin therapy (ITT), says the guidance.
The change is based on a new evidence-based paper published online May 23 in the American Journal of Medical Quality.

Completo aquí:

domingo, 9 de junio de 2013


A Requiem for Beta Blockers to Treat Hypertension?

A Future of Beta Blockers “Plus” to Treat Hypertension?

One Diuretic Remains Supreme

No benefit of fish oil in high-risk patients - Heartwire Mayo 2013

Milan, Italy - The supplemental use of n-3 fatty acids does not reduce the risk of cardiovascular morbidity and mortality in patients with multiple cardiovascular-disease risk factors [1].
These are the conclusions of the Risk and Prevention Study Collaborative Group, a collective of Italian researchers led by Maria Carla Roncaglioni (Mario Negri Institute of Pharmacological Research, Milan, Italy). In addition to having no effect on the study's primary end point in this group of patients with multiple cardiovascular risk factors or atherosclerotic disease, but no previous MI, the researchers did not observe any benefit on secondary end points, including death from coronary causes or sudden death from cardiac causes or major ventricular arrhythmias.
"Our findings provide no evidence of the usefulness of n-3 fatty acids for preventing cardiovascular death or disease in this population," write the researchers in the May 9, 2013 issue of the New England Journal of Medicine.
Dr James Stein (University of Wisconsin, Madison), who was not affiliated with the study, said in an email to heartwire that the results are disappointing but consistent with recent studies showing no significant effect of fish-oil supplements. "Especially interesting that there was no effect even in those with low baseline intake of omega-3 fats, those not on aspirin, and those not on statins," he commented.
In the analysis, the researchers did observe a significant interaction between the efficacy of n-3 fatty acids and sex (p=0.04), with women treated with fish oil having statistically significant 18% lower risk of the primary end point when compared with women treated with placebo. However, the investigators and Stein caution that the interaction should be interpreted cautiously and might simply be due to chance.

miércoles, 5 de junio de 2013

Daily Headlines: Long-Term Benefit of Bariatric Surgery Questioned

By Nancy Walsh, Staff Writer, MedPage Today

Published: June 04, 2013

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

For best viewing, click the bottom right corner for full screen.

Action Points

Bariatric surgery led to greater weight loss and better glycemic control than nonsurgical treatment among patients with diabetes who were mildly obese, but the evidence for long-term efficacy and safety remains limited.

Point out that in long-term follow-up of some studies in the systematic review, weight loss often was not maintained, although improvements in diabetes did remain.

Bariatric surgery led to greater weight loss and better glycemic control than nonsurgical treatment among patients with diabetes who were mildly obese, but the evidence for long-term efficacy and safety remains limited, a systematic review found.

In one of the three randomized studies included in the review, patients who had gastric bypass lost 29.4 kg (64.8 lb) and those who had sleeve gastrectomy lost 25.1 kg (55.3 lbs) over the course of a year, whereas patients on medical therapy lost only 5.4 kg (11.9 lb, P<0 .001="" according="" and="" angeles="" california="" colleagues.="" los="" maggard-gibbons="" md="" melinda="" of="" the="" to="" university="">

In addition, mean hemoglobin (Hb)A1c at 12 months was 6.4% in the gastric bypass group and 6.6% in the sleeve gastrectomy group, compared with 7.5% in the medical therapy group (P<0 .003="" 5="" american="" association.="" in="" journal="" june="" medical="" of="" reported="" researchers="" the="">

"Current evidence suggests that bariatric surgery is associated with more short-term weight loss and better intermediate glucose outcomes than nonsurgical therapy in patients with diabetes and a [body mass index] of 30 to 35," they wrote.

However, "it is unknown whether the benefits observed are durable long term and if these findings might translate into reductions in the microvascular and macrovascular complications of diabetes," they cautioned.

Bariatric surgery has demonstrated success for weight loss and comorbidities in morbidly obese patients whose body mass index (BMI) is 35 kg/m2 and higher, but whether individuals with less severe obesity and diabetes could also benefit has been controversial.

To examine the evidence for this, and to see if outcomes differed with the various procedures, Maggard-Gibbons and colleagues reviewed the literature and identified more than 50 studies with either direct or indirect comparisons.

In two of the three randomized trials, which altogether totaled 290 participants, patients not within the target population of BMI between 30 and 35 kg/m2 (the mean was 37) were included, but the reviewers considered the data to be "informative" nonetheless.

In one of these trials, a similar 13.8% weight loss occurred following gastric banding and intensive medical therapy at 6 months, but weight loss continued for an additional 18 months in the surgery group while the medical group regained most of the weight.

In another randomized trial, patients who underwent gastric banding lost 20 kg (44 lbs) more than patients on medical therapy by 2 years, and fasting glucose in the surgery group was 32.8 mg/dL lower.

"In support of this modest clinical trial evidence are direct comparisons of surgery and nonsurgical therapy in more obese populations and indirect comparisons of the associations between surgical and nonsurgical therapies and the outcomes of weight loss and glycemic control," the reviewers wrote.

For instance, in ten observational cohorts of patients, there were decreases of 3 percentage points in HbA1c 6 to 11 months after gastric bypass, 2.9 points after biliopancreatic diversion, and 2.5 points following sleeve gastrectomy.

And in observational studies of these procedures with follow-up of 1 to 2 years, decreases in HbA1c values ranged from 2.4 to 3.1 percentage points.

There were also several earlier systematic reviews that contributed data. In one review of behavioral weight-loss interventions versus usual care, relatively small changes in weight of 2 to 10 kg (4.4 to 22 lbs) were reported along with decreases in HbA1c of zero to 2 points.

Five other reviews of diabetes medications found decreases of 0.5 to 1 point in HbA1c per drug.

However, in long-term follow-up of some studies in the systematic review, weight loss often was not maintained, although improvements in diabetes did hold up.

There was only one death reported, in a patient who developed a perforation after gastric banding, and other complications following surgery such as infections and hernias were uncommon.

But there have been media reports of other deaths, and information about adverse events specifically in patients with diabetes and milder obesity has been lacking.

Therefore, according to the reviewers, "the evidence is insufficient to reach conclusions about the preferred treatment for diabetes in this target population due to the lack of long-term data on patients who have undergone bariatric surgery."

In contrast, there is abundant long-term data for medical treatment and behavioral interventions, including effects on the vascular outcomes.

Because of these persisting uncertainties, the reviewers concluded that until more data on bariatric surgery for these patients become available, "performance of these procedures in this target population should be under close scientific scrutiny, and additional studies comparing procedures are warranted."

Not everyone agrees with the need for delay, however. Eric Volckmann, MD, of the University of Utah in Salt Lake City, who was not involved in the study, told MedPage Today, "Weight-loss surgery hasn't been studied head-to-head with diabetes, but we do know a lot about the surgery. In the short-term, it does provide superior diabetes control compared with medical management. For many patients, it allows them for the first time in their lives to control their weight and related medical problems including diabetes."

The study was funded by the U.S. Department of Health and Human Services.

The authors also received support from the Agency for Healthcare Research and Quality, the Emergency Care Research Institute, VA Health Services, the Centers for Medicare & Medicaid Services, and the NIH.

Primary source: Journal of the American Medical Association

Source reference:

Maggard-Gibbons M, et al "Bariatric surgery for weight loss and glycemic control in nonmorbidly obese adults with diabetes: a systematic review" JAMA 2013; 309: 2250-2261.


Mediterran​ean diet slows atheroscle​rosis progressio​n in PREDIMED

Lyon, France - High adherence to a Mediterranean diet appears to slow the progression of carotid plaque, a PREDIMED substudy suggests. Of note, investigators found an attenuation of plaque progression in the Mediterranean diet arm of the study that included supplementation with nuts and no such change in the other intervention arm, which included supplemental extra virgin olive oil.

Dr Aleix Sala-Vila

This difference, however, may simply have been a product of limited sample size, Dr Aleix Sala-Vila (Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain) said here today at the European Atherosclerosis Society (EAS) 2013 Congress.

As previously reported by heartwire, PREDIMED was a large primary-prevention trial that randomized 7447 patients at high CV risk (but no CVD) to a control diet (including advice to reduce dietary fat) or Mediterranean diet (MedDiet) supplemented with extra virgin olive oil or mixed nuts (walnuts, almonds, and hazelnuts). After 4.8 years, the risk of major CV events (MI, stroke, death from CV causes) was reduced by 30% in the Mediterranean groups combined, compared with the control diet. The Mediterranean diet group assigned to the extra virgin olive oil supplementation saw a 30% reduction, while those in the nut supplementation group saw a 28% reduction, both compared with the control group.

In their latest analysis, Sala-Vila and colleagues looked at plaque volume and mean and maximum internal carotid-artery intima-media thickness (ICA-IMT). ICA-IMT, Sala-Vila explained to heartwire, may be a better indication of subclinical atherosclerosis and more predictive of CVD than measurements of common carotid-artery IMT.

Imaging insights

A total of 61 patients in the control group, 57 in the MedDiet plus supplementary olive-oil group, and 46 in the MedDiet plus nuts group underwent carotid ultrasound imaging at baseline and after a minimum of two years on their assigned diet.

After controlling for duration of time on the diet and changes in use or dose of statins, investigators saw a significant reduction in carotid plaque in the combined MedDiet group and MedDiet-plus-nuts group, but not in the MedDiet-plus-olive-oil group. A similar pattern was seen in both mean and maximum ICA-IMT.


Control (low-fat diet)

MedDiet plus olive oil

MedDiet plus nuts

Combined MedDiet

Plaque volume (maximum, mm3)





ICA-IMT (mean, mm)





ICA-IMT (maximum, mm)





ICA-IMT=internal carotid artery intima-medial thickness

*p<0 .05="" control="" vs="">

Speaking with heartwire, Sala-Vila was careful to point out the shortcomings of sonography for understanding plaque progression. But in a before-and-after example in his presentation, he showed that the width and apparent makeup of the plaque also changed over time.

"All we can say is that we saw regression of the volume of the plaque, that's it. But if you look here [at the baseline images], you can see an area of shadow that suggests lipid core, and over time, this shadow turns white—this typically means less lipid and more calcium, and this points to a more stable plaque."

The ICA-IMT results "can help explain, in part, the cardioprotective effects afforded by these types of foods, which are typical of the Mediterranean diet," Sala-Vila concluded.

Meaningful change?

Dr Emilio Ros

Also discussing the changes, senior author Dr Emilio Ros (Institut d'Investigacions Biomèdiques August Pi Sunyer) agreed that the changes in ICA-IMT were suggestive of the plaque progressing from lipid-rich to fibrous but that further insights will come from an MRI study now under way in the PREDIMED cohort.

He also noted that the changes reported, although small, are likely "meaningful" changes.

"Atherosclerosis always progresses, as you can see in the control group," Ros said. On IMT, this progression is typically in the range of 0.02 mm per year, he noted. "So what we can say is, there is progression in the control group, there is delayed progression in the olive-oil group, and there is a slight regression in the nuts group."