A brief office educational intervention improved referral rates for hypertension control in women.

As part of an initiative to increase physician awareness about hypertension and cardiovascular disease (CVD); we studied the effects of a pilot intervention on the rates of referral for uncontrolled hypertension in an Ob-Gyn office. Physicians in an Ob-Gyn practice completed an educational session regarding hypertension and used a 1-page tracking form in their medical records for 3 months. Trained personnel reviewed medical records to compare baseline rates of hypertension control to those at the end of the intervention. Rates of counseling about lifestyle modification to control hypertension were also documented. The rate of referral for hypertension was significantly increased after 3 months (p<0.001). The rates of counseling about CVD risk factors approached 100%. In this study, hypertension was commonly under-treated, despite being a major risk factor for CVD. As primary care physicians, obstetrician-gynecologists are in an excellent position to facilitate evaluation and treatment of hypertension in women. Education about the importance of hypertension control along with a simple tracking form can assist Ob-Gyn physicians in complying with JNC 7 guidelines.

Mortality in patients with microvascular disease.

Patients with chest pain/ischemic cardiac disease and normal coronary arteriography are thought to have a benign prognosis despite diminished quality of life. Many patients with hypertension fall into this group, at least in the early stage of their disease. Whether abnormalities in coronary flow reserve in these patients are associated with increased morbidity and mortality is unknown. One hundred sixty-eight patients with chest pain/ischemic cardiac disease and normal coronary angiograms who underwent invasive measures of coronary flow reserve were followed longitudinally. Mortality and quality of life were ascertained by query of the national death index and telephone administration of standardized questionnaires. Patient follow-up occurred at a mean of 8.5 years. In the abnormal coronary flow reserve group, 12 deaths (20%) were documented in 60 patients compared with eight out of 108 patients (7%; p=0.016) with normal coronary flow reserve. Coronary flow reserve did not predict impairment in functional health status in long-term follow-up. Thus, invasive measures of coronary flow reserve in patients with chest pain/ischemic cardiac disease and normal coronary angiograms predicted increased mortality. Surviving patients with chest pain/ischemic cardiac disease and normal coronary angiograms have significant morbidity.

The presence of African American race predicts improvement in coronary endothelial function after supplementary L-arginine.

OBJECTIVES: The purpose of our study was to determine if the presence of African American ethnicity modulates improvement in coronary vascular endothelial function after supplementary L-arginine. BACKGROUND: Endothelial dysfunction is an early stage in the development of coronary atherosclerosis and has been implicated in the pathogenesis of hypertension and cardiomyopathy. Amelioration of endothelial dysfunction has been demonstrated in patients with established coronary atherosclerosis or with risk factors in response to infusion of L-arginine, the precursor of nitric oxide. Racial and gender patterns in L-arginine responsiveness have not, heretofore, been studied. METHODS: Invasive testing of coronary artery and microvascular reactivity in response to graded intracoronary infusions of acetylcholine (ACh) +/- L-arginine was carried out in 33 matched pairs of African American and white subjects with no angiographic coronary artery disease. Pairs were matched for age, gender, indexed left ventricular mass, body mass index and low-density lipoprotein cholesterol. RESULTS: In addition to the matching parameters, there were no significant differences in peak coronary blood flow (CBF) response to intracoronary adenosine or in the peak CBF response to ACh before L-arginine infusion. However, absolute percentile improvement in CBF response to ACh infusion after L-arginine, as compared with before, was significantly greater among African Americans as a group (45 +/- 10% vs. 4 +/- 6%, p = 0.0016) and after partitioning by gender. The mechanism of this increase was mediated through further reduction in coronary microvascular resistance. L-arginine infusion also resulted in greater epicardial dilator response after ACh among African Americans. CONCLUSIONS: We conclude that intracoronary infusion of L-arginine provides significantly greater augmentation of endothelium-dependent vascular relaxation in those of African American ethnicity when compared with matched white subjects drawn from a cohort electively referred for coronary angiography. Our findings suggest that there are target populations in which supplementary L-arginine may be of therapeutic benefit in the amelioration of microvascular endothelial dysfunction. In view of the excess prevalence of cardiomyopathy among African Americans, pharmacologic correction of microcirculatory endothelial dysfunction in this group is an important area of further investigation and may ultimately prove to be clinically indicated.

Unstable angina.

Preview Because unstable angina is often a precursor of myocardial infarction or death, patients with chest pain that persists for more than 20 minutes and is refractory to sublingual nitroglycerin should be hospitalized in an intensive care unit and given appropriate pharmacologic therapy. If symptoms persist despite adequate management with drugs, coronary arteriography should be performed and consideration given to an invasive procedure, such as angioplasty or coronary artery bypass grafting, for high-risk conditions. If necessary, the invasive procedure should be delayed until the patient's condition has stabilized.

Hypertensive heart disease.

Preview Americans often think of coronary artery disease as the most common cardiac disorder, but hypertensive heart disease is estimated to occur in nearly three times more patients, affecting about 20 million Americans. The authors discuss current criteria for diagnosis of hypertensive heart disease, common manifestations, coexisting conditions, comparative sensitivity of diagnostic methods, and treatment goals.