Long-term follow-up of moderately hypercholesterolemic hypertensive patients following randomization to pravastatin vs usual care: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT).

The authors conducted a randomized, controlled, multicenter trial, in which they assigned well-controlled hypertensive participants aged 55 years and older with moderate hypercholesterolemia to receive pravastatin (n=5170) or usual care (n=5185) for 4 to 8 years, when trial therapy was discontinued. Passive surveillance using national databases to ascertain deaths and hospitalizations continued for a total follow-up of 8 to 13 years to assess whether mortality and morbidity differences persisted or new differences developed. During the post-trial period, fatal and nonfatal outcomes were available for 98% and 64% of participants, respectively. The primary outcome was all-cause mortality and the secondary outcomes included cardiovascular mortality, coronary heart disease (CHD), stroke, heart failure, cardiovascular disease, and end-stage renal disease. No significant differences appeared in mortality for pravastatin vs usual care (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.89-1.03) or other secondary outcomes. Similar to the previously reported in-trial result, there was a significant treatment effect for CHD in black patients (HR, 0.79; 95% CI, 0.64-0.98). However, the in-trial result showing a significant treatment by race effect did not remain significant during the entire follow-up (P=.08). These findings are consistent with evidence from other large trials that show statins prevent CHD and add evidence that they are effective for CHD prevention in black patients.

A stuttering discovery of lithium toxicity.

An 86-year-old female nursing home resident was typically described by the nursing staff as alert, pleasant, and conversant, although disoriented to time and place at times. She was frequently seen in the hallways, often breaking into song with her melodious voice. Her past medical history was significant for dementia, epilepsy, and bipolar disorder, for which she took lithium carbonate. One day, she complained to her nurse that she had been stuttering, finding it difficult to complete a sentence, as well as sing. This persisted for 3 more months until a lithium level was checked, and came back elevated at 2.0 mmol/L (0.6 to 1.2 mmol/L). Lithium carbonate was promptly stopped and after about 2 weeks, her stuttering had completely resolved. We found considerable interest in this case, as lithium has rarely been associated with drug-induced stuttering. We reviewed drug-induced stuttering, enumerated the medications implicated in various case reports, and discussed its mechanisms and management.

Heart failure in frail, older patients: we can do 'MORE'.

A comprehensive approach is necessary in managing heart failure in frail older adults. To provide optimal care, physicians need to draw on knowledge from the fields of internal medicine, geriatrics, and cardiology. The acronym "MORE" is a mnemonic for what heart failure management should include: multidisciplinary care, attention to other (ie, comorbid) diseases, restrictions (of salt, fluid, and alcohol), and discussion of end-of-life issues.

Steroid-induced hallucination following intra-articular administration: a case report and brief review.

Amidst the ubiquitous use of steroids, psychiatric side-effects are not uncommon, though the presentation may be curiously diverse. The case of an elderly lady who had 40 mg of methylprednisolone injected in each knee for treatment of suprapatellar bursitis is presented. After 3 days, she reported visual hallucinations, which resolved without treatment 6 days after the steroid injections. We found considerable interest in this case as there were very few reported cases of adverse psychiatric events triggered by intra-articular steroid administration. We follow with a brief review of the incidence, risk factors, presentation, and treatment of steroid-induced psychiatric side-effects.

Dietary supplements in primary care. Botanicals can affect surgical outcomes and follow-up.

Dietary supplements are commonly used by patients of all ages, yet few patients reveal use of these products to their medical providers. Certain dietary supplements can react or interact with frequently used surgical medications--including anesthesia--and may cause serious unforeseen consequences or complications. Arrhythmias, poor wound healing, bleeding, photosensitivity reaction, and prolonged sedation are among the serious reactions during and after surgical and diagnostic procedures that have been attributed to these products. This article reviews the effects of the Few Gs (feverfew, ginkgo biloba, garlic, ginseng, and ginger), valerian, kava, St. John's wort, ephedra (Ma huang or metabolite), and echinacea. We recommend that all patients be advised to stop all dietary supplements at least 1 week prior to major surgical or diagnostic procedures; if a complication is noted, continued use of these products should be reviewed with patients.

Cardiovascular outcomes using doxazosin vs. chlorthalidone for the treatment of hypertension in older adults with and without glucose disorders: a report from the ALLHAT study.

Insulin resistance underlies most glucose disorders in adults and is associated with an increased risk of cardiovascular disease. Alpha blockers decrease insulin resistance, whereas diuretics increase insulin resistance. The authors studied the effects of these two classes of hypertension medications (doxazosin, an a blocker, and chlorthalidone, a diuretic) on cardiovascular disease outcomes in adults aged >55 years with hypertension and glucose disorders who were participants in the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (8749 had known diabetes mellitus and 1690 had a newly diagnosed glucose disorder [fasting glucose >/=110 mg/dL]). There was no difference in either group between the chlorthalidone- and doxazosin-based treatments with regard to fatal or nonfatal myocardial infarction or all-cause mortality. There was, however, a difference for combined cardiovascular disease (myocardial infarction, revascularization procedures, angina, stroke, heart failure, and peripheral arterial disease) in favor of the diuretic. This difference was due primarily to an increased heart failure risk in those treated with doxazosin (relative risk, 1.85; 95% confidence interval, 1.56-2.19) in the known diabetes mellitus group and a relative risk of 1.63 (95% confidence interval, 1.05-2.55) in those with a newly diagnosed glucose disorder despite lower glucose levels on follow-up in those treated with a blockers. The authors conclude that treatment of hypertension with doxazosin in adults with glucose disorders incurs the same risk of coronary heart disease as treatment with chlorthalidone; however, treatment with doxazosin increases the risk of combined cardiovascular disease and heart failure despite lower glucose levels.

Blood Pressure Therapy in the Elderly: An Observation in Octogenarians.

The incidence of hypertension increases with age. Although there is ample evidence regarding the benefit of treating elderly hypertensive patients, resulting in decreases in cardiovascular morbidity and mortality, the adverse effects of treatment are also frequently reported in these often frail individuals. Therefore, it is difficult to determine the level to which blood pressure should be decreased and what type of antihypertensive medication is most effective and best tolerated. The approach to treating hypertension in octogenarians at the Cleveland Clinic Florida was reviewed. An analysis of 100 consecutive charts of hypertensive octogenarians treated by internists from January 1, 1993, with a minimum of 1 year follow up, was carried out. The mean age of the population studied was 84.7 years (range, 80-97Â+/-4.13 years). The mean initial blood pressure was 152/83 mm Hg, and the mean final blood pressure was 145/76 mm Hg (pless than 0.01). The initial number of medications used was 1.2, which rose to 1.6 by the final reading (pless than 0.0001). The most frequently used drug classes were calcium channel blockers, followed by diuretics and ACE inhibitors. Most of the octogenarians tolerated their antihypertensive medication well. (c)2000 by Le Jacq Communications, Inc.