Complex Cardiovascular Morbidities in Prader-Willi Syndrome: A Multidisciplinary Approach.

This case emphasizes the complexity of Prader-Willi syndrome (PWS), the need for a collaborative approach from specialists, and a closer look at the various cardiovascular complexities associated with this syndrome. While current treatments focus on managing symptoms, ongoing genetic research offers hope for more favorable outcomes. Further studies are crucial to gauge the effectiveness of these treatments for PWS patients. We detail a patient with a complex medical history of PWS, further complicated by congenital heart disease with Eisenmenger's syndrome, diabetes mellitus, pulmonary hypertension, venous insufficiency, hypothyroidism, and hyperlipidemia. Reported in this study is a compilation of clinical data as well as suggestions from several medical specialists in applying a multifaceted approach to treatment, significantly emphasizing the need for interdisciplinary care and management of patients experiencing a combination of various medical issues with an emphasis on cardiovascular complications.

In hypertension, with or without orthostatic hypotension, more- vs. less-intensive BP therapy improves clinical outcomes.

SOURCE CITATION: Juraschek SP, Hu JR, Cluett JL, et al. Orthostatic hypotension, hypertension treatment, and cardiovascular disease: an individual participant meta-analysis. JAMA. 2023;330:1459-1471. 37847274.

In low-risk penicillin allergies, direct oral challenge was noninferior to skin testing followed by oral challenge.

SOURCE CITATION: Copaescu AM, Vogrin S, James F, et al. Efficacy of a clinical decision rule to enable direct oral challenge in patients with low-risk penicillin allergy: the PALACE randomized clinical trial. JAMA Intern Med. 2023;183:944-952. 37459086.

Sodium Homeostasis and Hypertension.

PURPOSE OF REVIEW: This review aims to summarize and discuss the relationship between sodium homeostasis and hypertension, including emerging concepts of factors outside cardiovascular and renal systems influencing sodium homeostasis and hypertension. RECENT FINDINGS: Recent studies support the dose-response association between higher sodium and lower potassium intakes and a higher cardiovascular risk in addition to the dose-response relationship between sodium restriction and blood pressure lowering. The growing body of evidence suggests the role of genetic determinants, immune system, and gut microbiota in sodium homeostasis and hypertension. Although higher sodium and lower potassium intakes increase cardiovascular risk, salt restriction is beneficial only to a certain limit. The immune system contributes to hypertension through pro-inflammatory effects. Sodium can affect the gut microbiome and induce pro-inflammatory and immune responses that contribute to salt-sensitive hypertension.

In adults with hypertension, effects of BP-lowering drug monotherapy varied by patient.

SOURCE CITATION: Sundström J, Lind L, Nowrouzi S, et al. Heterogeneity in blood pressure response to 4 antihypertensive drugs: a randomized clinical trial. JAMA. 2023;329:1160-1169. 37039792.

In BPPV, canalith repositioning maneuver increased symptom resolution vs. vestibular suppressants.

SOURCE CITATION: Sharif S, Khoujah D, Greer A, et al. Vestibular suppressants for benign paroxysmal positional vertigo: a systematic review and meta-analysis of randomized controlled trials. Acad Emerg Med. 2022. [Epub ahead of print.] 36268806.

In hypertension, evening vs. morning dosing of antihypertensive drugs did not differ for major CV outcomes at 5.2 y.

SOURCE CITATION: Mackenzie IS, Rogers A, Poulter NR, et al. Cardiovascular outcomes in adults with hypertension with evening versus morning dosing of usual antihypertensives in the UK (TIME study): a prospective, randomised, open-label, blinded-endpoint clinical trial. Lancet. 2022;400:1417-25. 36240838.

A Rare Case of Page Kidney With Superimposed Infection.

Page kidney (PK) is a rare renal condition characterized by external compression of the kidney, typically by a subcapsular hematoma, leading to resistant secondary hypertension due to hypoperfusion and ischemia. This hypertension is caused by the external compression of the kidney by a chronic subcapsular hematoma that activates the renin-angiotensin-aldosterone system (RAAS) system. Hematoma formation can result from external or internal trauma. The resolution of the hematoma can take months, and, in some cases, may necessitate a nephrectomy. Unresolved subcapsular hematomas can be complicated by infection, leading to sepsis, hospitalization, and the need for surgical drainage. This report presents a unique case of a 67-year-old female with a spontaneous left renal subcapsular hematoma that did not resolve with conservative measures and was complicated by superimposed infection requiring percutaneous drainage.

Breakthrough SARS-CoV-2 infections after COVID-19 immunization.

As no vaccines are 100% effective at preventing illness, COVID-19 vaccine breakthrough cases are expected. We here aim to review the most recent literature on COVID-19 vaccine breakthrough infections. SARS-CoV-2 breakthrough infections are, in general, rare. Age may still be a factor in SARS-CoV-2 infections in immunized individuals.

Methods of Blood Pressure Measurement to Predict Hypertension-Related Cardiovascular Morbidity and Mortality.

PURPOSE OF REVIEW: As the evidence on different blood pressure phenotypes and their cardiovascular risks evolve, it is imperative to evaluate the reliability of office blood pressure (OBP), ambulatory blood pressure (ABP), and home blood pressure (HBP) measurements and their associations with cardiovascular morbidity and mortality. RECENT FINDINGS: HBP is more reliable in diagnosis of hypertension than OBP or ABP. HBP correlates better with left ventricular mass index (LVMI). Increasing systolic HBP is associated with a higher risk of all-cause mortality, cardiovascular mortality, and cardiovascular events. An elevated systolic ABP is also associated with a higher risk of cardiovascular events and mortality. ABP is a better predictor of cardiovascular events than OBP in diabetics. ABP and HBP furnish additional information beyond OBP. They correlate better with cardiovascular outcomes and are more helpful with monitoring therapy than OBP. Comparative effectiveness studies of all three methods associating with cardiovascular outcomes are warranted.

USPSTF found insufficient evidence on benefits and harms of screening for vitamin D deficiency in asymptomatic adults.

SOURCE CITATION: Krist AH, Davidson KW, Mangione CM, et al. Screening for vitamin D deficiency in adults: US Preventive Services Task Force recommendation statement. JAMA. 2021;325:1436-42. 33847711.

Insufficient evidence for benefits/harms of cognitive impairment screening in asymptomatic older adults.

SOURCE CITATION: US Preventive Services Task Force, Owens DK, Davidson KW, et al. Screening for cognitive impairment in older adults: US Preventive Services Task Force recommendation statement. JAMA. 2020;323:757-63. 32096858.

Mortality and Cardiovascular Disease in Type 1 and Type 2 Diabetes.

PURPOSE OF REVIEW: The aims of this review are to summarize recent data on mortality and cardiovascular disease (CVD) in type 1 and type 2 diabetes and to determine the interventions that could have contributed to a reduction in mortality. RECENT FINDINGS: Recent studies found a downward trend in mortality and CVD among both diabetics and non-diabetics worldwide over the last few decades. The decline among diabetics is steeper than that among non-diabetics. Despite a parallel trend of decline, an approximately twofold difference in mortality and CVD between the two populations remains. A greater emphasis on glycemic control, management of cardiovascular risk factors, quality improvement programs, and advances in treatment of conditions associated diabetes are the factors that potentially contributed to the improvement. Although the trend is encouraging, a rising prevalence of diabetes will continue the absolute disease burden to the society. Future interventions should focus on prevention of diabetes.

Relationship Between Outpatient Clinic and Ambulatory Blood Pressure Measurements and Mortality.

PURPOSE OF REVIEW: This review aims to summarize and discuss the relationship between outpatient clinic and ambulatory blood pressure (BP) measurements and cardiovascular morbidity and mortality. RECENT FINDINGS: Contemporary clinical practice guidelines worldwide recommend ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. Recent epidemiological studies and systematic reviews showed ABPM predicts cardiovascular events and mortality independent of clinic BP. Ambulatory BP appears to be prognostically superior to clinic BP. ABPM characterizes BP phenotypes that would not have otherwise identified with clinic BP measurement only. Identification of white coat hypertension, which carries a prognosis almost similar to normotension, and masked hypertension, which carries a prognosis almost similar to sustained hypertension, can be accomplished only by ABPM. Randomize controlled trials to assess the cardiovascular effects of hypertensive patients managed with ABPM vs. clinic BP measurement and cost-effective studies of ABPM are warranted.

Thiazide diuretics and the risk of hip fracture.

BACKGROUND: Thiazide diuretics are one of the most commonly prescribed antihypertensive agents worldwide. Thiazides reduce urinary calcium excretion. Chronic ingestion of thiazides is associated with higher bone mineral density. It has been suggested that thiazides may prevent hip fracture. However, there are concerns that diuretics, by increasing the risk of fall in elderly, could potentially negate its beneficial effects on hip fracture. OBJECTIVES: To assess any association between the use of thiazide diuretics and the risk of hip fracture in adults. SEARCH STRATEGY: We searched eligible studies up to December 2008 in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), International Pharmaceutical Abstracts, the Database of Abstracts of Review of Effects (DARE) and reference lists of previous reviews and included studies. SELECTION CRITERIA: All randomized controlled trials and observational studies, which assessed the association between thiazide diuretic use and hip fracture. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the selection criteria, extracted data and assessed risk of bias of each study selected.  The results were summarized descriptively and quantitatively. Cohort studies and case control studies were analysed separately. MAIN RESULTS: No randomized control trials were found. Twenty-one observational studies with nearly four hundred thousand participants were included. Six of them were cohort studies and 15 were case-control studies. Two cohort studies appear to involve the same cohort so there were only 5 unique ones. The risk of bias was assessed with the Newcastle-Ottawa Scale (NOS). Five cohort studies had low risk of bias and one had moderate risk of bias. Seven case control studies had low risk of bias and 8 had moderate risk of bias. Meta-analysis of cohort studies showed that thiazide use was associated with a reduction in risk of hip fracture by 24%, pooled RR 0.76 (95% CI 0.64-0.89; p = 0.0009). We chose not to provide a pooled summary statistics for case-control studies because of high heterogeneity (Tau(2) = 0.03, I(2) = 62%, p = 0.0008). AUTHORS' CONCLUSIONS: Thiazides appear to reduce the risk of hip fracture based on observational studies. Randomized controlled trials are needed to confirm these findings.  

Vasopressin for cardiac arrest: a systematic review and meta-analysis.

BACKGROUND: The current guidelines for cardiopulmonary resuscitation recommend vasopressin as an alternative to epinephrine for the treatment of adult shock-refractory ventricular fibrillation. The objective of this study was to determine the effectiveness of vasopressin in the treatment of cardiac arrest. METHODS: We performed a systematic review and meta-analysis of 1519 patients with cardiac arrest from 5 randomized controlled trials that compared vasopressin and epinephrine. Two reviewers conducted a systematic search of electronic databases, complemented by hand searches, to identify randomized trials. Reviewers evaluated the quality of the trials, extracted data, and derived pooled estimates using a random-effects model. RESULTS: There were no statistically significant differences between the vasopressin and epinephrine groups in failure of return of spontaneous circulation (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.58-1.12), death before hospital admission (RR, 0.72; 95% CI, 0.38-1.39), death within 24 hours (RR, 0.74; 95% CI, 0.38-1.43), death before hospital discharge (RR, 0.96; 95% CI, 0.87-1.05), or combination of number of deaths and neurologically impaired survivors (RR, 1.00; 95% CI, 0.94-1.07). Subgroup analysis based on initial cardiac rhythm showed no statistically significant difference in the rate of death before hospital discharge between the vasopressin and epinephrine groups in any of the 3 subgroups: ventricular fibrillation or ventricular tachycardia (RR, 0.97; 95% CI, 0.79-1.19), pulseless electrical activity (RR, 1.02; 95% CI, 0.95-1.10), or asystole (RR, 0.97; 95% CI, 0.94-1.00). CONCLUSIONS: There is no clear advantage of vasopressin over epinephrine in the treatment of cardiac arrest. Guidelines for Advanced Cardiac Life Support should not recommend vasopressin in resuscitation protocols until more solid human data on its superiority are available.