Blood pressure as a predictor of cardiovascular events in the elderly: the William Hale Research Program.

This study evaluates the association between blood pressure (BP) and the risk of developing cardiovascular disease (CVD) events in the elderly. The Morton Plant Mease Foundation has followed 4,008 elderly patients >64 years of age for at least 5 years. Systolic and diastolic blood pressure (SBP and DBP) was divided into categories. Cardiovascular disease events were classified as myocardial infarction, stroke, and CVD-related deaths reported from the National Death Index. Cox proportional hazard ratios were used to assess the relationship between BP and CVD events and controlled for weight, gender, smoker, and alcohol use. Ages <75 and >or=75 years were assessed separately. After 11.1 years of follow-up, elevated SBP (P=<0.0001) is strongly associated with developing a future CVD event; the relationship is linear and graded and holds for ages above and below 75 years. The frequency of CVD events was lowest in the SBP <120 mm Hg group. In subjects <75 years of age, DBP elevations were not a significant risk factor for CVD events. (relative risk (RR): DBP 70 to <80 mm Hg=0.92; DBP 80 to <90 mm Hg=0.88; DBP >or=90 mm Hg=1.02.) With subjects >or=75 years of age, a DBP between 80 and 90 is associated with the lowest significant risk for CVD (RR: DBP 70 to <80 mm Hg=0.74; DBP 80 to <90 mm Hg=0.59; DBP >or=90=0.71). In conclusion, these findings support the Joint National Committee on Hypertension recommendations for SBP in the elderly. Further studies are warranted to identify optimal DBP for the elderly at various ages.

Group office visits change dietary habits of patients with coronary artery disease-the dietary intervention and evaluation trial (D.I.E.T.).

BACKGROUND: We evaluated the effectiveness of a low-cost group visit intervention for changing the dietary intake and lipid levels of patients with known coronary artery disease (CAD). METHODS: We performed a controlled random group assignment trial in 4 community outpatient clinics. The Dietary Intervention and Evaluation Trial randomized 97 patients with CAD to either a control group that followed the National Cholesterol Education Program's Step II-III diet plan (n=48) or an experimental group that received meal plans, recipes, and nutritional information during monthly group office sessions (n=49). Both groups received lipid-lowering medications and were followed-up over 12 months. We assessed dietary intake, fasting lipid profiles, hemoglobin A1C levels, and per member per month (PMPM) expense data. RESULTS: Food frequency data showed that eating fruits and vegetables and cooking with monounsaturated fat increased significantly in the experimental group compared with the control group at 1 year (P=.0072; P=.0001; P=.0004). The total PMPM expenses decreased for both groups (38% for the experimental group and 10% for the control group), but the cost difference was statistically nonsignificant (P=.2975). Both groups noted low-density lipoprotein reductions, significant only in the experimental group (P=.0035). CONCLUSIONS: Our study suggests that using group office visits for patients with CAD was an effective method for helping subjects make dietary changes and for improving lipid levels. Patients with known CAD and elevated lipid levels were willing to make significant lifestyle changes when offered a program that emphasizes healthy foods in a group visit format.

Dietary therapy for preventing and treating coronary artery disease.

Nearly one half of Americans die of cardiovascular disease. The morbidity and mortality associated with coronary artery disease is strongly related to abnormal lipid levels, oxidation of lipids and intra-arterial clot formation. Nutrition powerfully influences each of these factors. There is growing evidence that patients can improve lipid levels and decrease the rate of cardiovascular events by "adding" specific foods to their diets and switching from saturated and polyunsaturated to monounsaturated fats and n-3 fatty acids. Appropriate dietary changes decrease arteriosclerotic plaque formation, improve endothelial vasomotor dynamics, reduce oxidation of low-density lipoproteins and enhance thrombolytic activity. Brief discussions between physicians and patients can influence patients' food choices. Changes in diet can reduce the premature mortality and morbidity associated with coronary artery disease.

Malaria: chemoprophylaxis and therapy.

Malaria should be considered in a patient with unexplained fever and a history of travel to an endemic area. Aggressive therapy must be started if Plasmodium falciparum infection is a possibility. Travelers must be educated about mosquito bite protection and appropriate chemoprophylaxis. Travelers can, however, acquire malaria despite chemoprophylaxis, and symptoms may appear up to one year after the trip.

Wolff-Parkinson-White syndrome. Termination of paroxysmal supraventricular tachycardia with phenylephrine.

A patient with Wolff-Parkinson-White syndrome, susceptible to tachydysrhythmias , presented for eye surgery under general anaesthesia. He developed a supraventricular tachycardia refractory to a variety of treatments. Phenylephrine consistently abolished the dysrhythmia, probably by acting directly to stimulate the arterial baroreceptors and hence vagal output. Vasopressor therapy should be considered in Wolff-Parkinson-White syndrome tachyarrhythmias, when circumstances permit.