Harmful Effects of NSAIDs among Patients with Hypertension and Coronary Artery Disease

There is limited information regarding the safety of chronic non-steroidal anti-inflammatory drugs (NSAIDs) in hypertensive patients with coronary artery disease. This research study found that among hypertensive patients with coronary artery disease, chronic self-reported NSAID use over a mean of 2.7 years was associated with a 47% increase in the first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.

Abstract

Background
There is limited information about the safety of chronic nonsteroidal anti-inflammatory drugs (NSAIDs) in hypertensive patients with coronary artery disease.

Methods
This was a post hoc analysis from the INternational VErapamil Trandolapril STudy (INVEST), which enrolled patients with hypertension and coronary artery disease. At each visit, patients were asked by the local site investigator if they were currently taking NSAIDs. Patients who reported NSAID use at every visit were defined as chronic NSAID users, while all others (occasional or never users) were defined as nonchronic NSAID users. The primary composite outcome was all-cause death, nonfatal myocardial infarction, or nonfatal stroke. Cox regression was used to construct a multivariate analysis for the primary outcome.

Results
There were 882 chronic NSAID users and 21,694 nonchronic NSAID users (n = 14,408 for never users and n=7286 for intermittent users). At a mean follow-up of 2.7 years, the primary outcome occurred at a rate of 4.4 events per 100 patient-years in the chronic NSAID group, versus 3.7 events per 100 patient-years in the nonchronic NSAID group (adjusted hazard ratio [HR] 1.47; 95% confidence interval [CI], 1.19-1.82; P=.0003). This was due to an increase in cardiovascular mortality (adjusted HR 2.26; 95% CI, 1.70-3.01; P<.0001). Conclusion
Among hypertensive patients with coronary artery disease, chronic self-reported use of NSAIDs was associated with an increased risk of adverse events during long-term follow-up.

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-- Anthony A. Bavry, MD, MPH, Asma Khaliq, MD, Yan Gong, PhD, Eileen M. Handberg, PhD, Rhonda M. Cooper-DeHoff, PharmD, MS, Carl J. Pepine, MD

This article originally appeared in the July 2011 issue of The American Journal of Medicine.

Should the Affordable Care Act of 2010 Be Repealed?

Most Republicans in the 112th Congress pledged to repeal the Affordable Care Act of 2010. When Speaker of the House John Boehner was asked why the Republicans want to repeal the Affordable Care Act, he replied: “because ‘Obamacare’ would destroy the best health care delivery system in the world” (NBC News, January 6, 2011).(1)

Does the US Have the Best Health Care Delivery System in the World? Do All Americans Have Access to It?
There are many reasons why one would expect the US to have the best health care delivery system in the world. We have a well-educated population with a high standard of living. We have well-trained health professionals and well-equipped hospitals and clinics. And most of all, we spend far more on health care than any country in the world!(2)

If we have the world's best health care system, it follows that we would have the world's best health care outcomes. We don't! We lag behind other industrial nations in life expectancy, infant mortality, maternal mortality, and immunization rates.2 In 2000, the World Health Organization ranked our health care system as the 37th best among 119 nations. We ranked #17 of 17 industrial nations.(3)

Why We Don't Have the World's Best Health Care System: The Uninsured
The reason that we do not fare well in these health outcomes is that many of our citizens do not have access to ongoing primary and preventive care. To have access to ongoing preventive care, one must have adequate health insurance. In our country, up to 22% of our citizens were uninsured or had inadequate health insurance in 2007.(4) Those without adequate insurance can seek help for emergencies in our hospitals' overcrowded emergency rooms—but where do they go for ongoing preventive care?

The uninsured at greatest risk are those with chronic conditions. Nearly 40% of our population have a chronic condition such as diabetes, hypertension, asthma, or heart disease.5 These conditions require ongoing physician care and nearly always require prescription drugs.

Multiple studies document that patients with chronic conditions who are uninsured are less likely to have a usual source of health care, do not see a physician at least once a year, and have an unmet need for prescription drugs for their condition.(5)

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-- James E. Dalen, MD, MPH

This article originally appeared in the July 2011 issue of The American Journal of Medicine.

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Cardiovascular Risk Factors in Patients with Lichen Planus

When this research group analyzed metabolic syndrome parameters, they found a significantly higher prevalence of dyslipidemia in lichen planus patients. Chronic inflammation in patients with lichen planus may explain the association with dyslipidemia.

Abstract

Background
Chronic inflammation was found to play an important role in the development of cardiovascular risk factors. Recently a case-control study found that lichen planus was associated with dyslipidemia in a large series of patients. However, no data were presented about lipid values, glucose levels, or blood pressure.

Objective
The objective of this case-control study was to evaluate cardiovascular risk factors included in Adult Treatment Panel III criteria for metabolic syndrome in men and women with lichen planus and in healthy controls.

Patients and Methods
This case-control study included 200 patients, 100 with lichen planus (50 men and 50 women) and 100 controls consecutively admitted to the outpatient clinic in Dermatology departments in Granada, Spain.

Results
Analysis of metabolic syndrome parameters revealed a higher significant prevalence of dyslipidemia in patients with lichen planus. No significant differences were observed in glucose levels, abdominal obesity, or blood pressure. Elevated levels of C-reactive protein, erythrocyte sedimentation rate, and fibrinogen were noted in patients with lichen planus. Adjusted odds ratio for dyslipidemia in patients with lichen planus was 2.85 (95% confidence interval, 1.33-5.09; P=.001).

Conclusion
Chronic inflammation in patients with lichen planus may explain the association with dyslipidemia. Lipid levels screening in men or women with lichen planus may be useful to detect individuals at risk and start preventive treatment against the development of cardiovascular disease.

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-- Salvador Arias-Santiago, PhD, Agustín Buendía-Eisman, PhD, José Aneiros-Fernández, MD, María Sierra Girón-Prieto, MD, María Teresa Gutiérrez-Salmerón, PhD, Valentín García Mellado, PhD, Ramón Naranjo-Sintes, PhD

This article originally appeared in the June 2011 issue of The American Journal of Medicine.

AJM Editor-in-Chief previews the July issue (video)

The July 2011 issue of The American Journal of Medicine is live online at http://amjmed.com. For a preview of important research in this issue, check out this video with Editor-in-Chief Joseph S. Alpert, MD.

Male Infertility And Lack Of Omega-3

Introduction

Did you know that a lack of DHA (docosahexaenoic acid) could cause men to become infertile? Well there have been some recent studies performed that seem to indicate that a lack of the fatty acid DHA could cause men to become infertile.

Studies

Before getting into the studies lets define some terms:
Knockout Mice - Are mice that have been genetically engineered to turn off one or more of its genes.
Motile - As used in this article, defines the ability of the sperm to swim in the right direction towards the egg.

A study performed at the University of Illinois, using knockout mice, which lacked the enzyme important for developing DHA, found that these mice were incapable of breeding. They also found that these knock out mice had low sperm count, the sperm was rounded instead of elongated, and sperm that were less motile.

When the scientist introduced DHA into the diet, the mice were able to reproduce.

In another study performed on 150 men in Iran and published by the journal "Clinical Nutrition" (February 2010, Vol. 29, pp. 100-105), found that infertile men had lower levels of Omega-3 in their sperm than fertile men.

Other studies coming out of Europe and Canada support these findings. But in all studies, they state that more studies are needed to find the mechanism, which causes infertility in men by having a lack of DHA.

Western Diet

If this is true, that a lack of DHA can cause infertility in men, then the Western civilization is a dying breed. About 150 years ago, our diet shifted from one, which consumed natural foods rich in Omega-3 to processed foods, which is deficient in Omega-3 but rich in Omega-6.

What this means is that we are not getting the Omega-3 we need for our body's health and possibly to prevent infertility in Western men.

Diet Change

If this is true, that DHA can cause infertility in men, then men should look at their diet and ensure they are receiving enough Omega-3, not only to ensure they are fertile, but also for their health.

Ensure your diet includes up to three servings a week of cold-water fish such as trout, salmon, cod, halibut, sardines and anchovies.

Conclusion

There have been several studies that have shown a link between infertility in men and a lack of DHA. Though these studies are not conclusive, men should be aware of these studies and ensure they are getting the proper amount of Omega-3.

Web of Confusion

The occurrence of a late-stage complication in a patient with early disease, reminds us that any illness can take an unpredictable course. A 63-year-old man presented with complaints of fatigue and rash. He had been in his usual state of health until approximately 2 months prior, when he developed decreased visual acuity in his right eye. He was seen by a local ophthalmologist, who diagnosed nonarteritic ischemic optic neuritis and prescribed a daily aspirin. Soon thereafter, the patient noticed that he was having trouble moving about his house and working, and he felt as if he needed to sit and rest often. Additionally, he admitted to night sweats and a 15-lb weight loss. Upon questioning, he also reported that he had developed a nonpruritic rash on his legs and torso. He denied headache, joint pain, myalgia, morning stiffness, jaw claudication, weakness, cough, or shortness of breath. He took no medications other than a daily adult aspirin.

On examination, the patient exhibited livedo reticularis involving his lower limbs, buttocks, and lower torso circumferentially.

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-- Craig G. Gunderson, MD, Daniel G. Federman, MD

This article originally appeared in the June 2011 issue of The American Journal of Medicine.

HITECH, Electronic Health Records, and Facebook: A Health Information Trifecta

In enacting the Health Information Technology for Economic and Clinical Health (HITECH) Act, the Obama administration has devoted unparalleled resources to incentivize “the adoption and meaningful use of health information technology.” One important reason for this revolutionary legislation is the notion that information technology can improve health safety, quality, and efficiency. The vehicle of this transformation, electronic health record systems, promises a singular, standardized and universally accessible source of information, enabling data sharing across entities vested in patient care. Electronic health records facilitate abstraction of large quantities of information for research or quality improvement, modernize billing processes, and impact patient care by both reducing complications during hospitalization and lowering readmission rates. They also can serve important roles in the monitoring, measuring, and reporting of quality, safety, and efficiency. (1, 2, 3)

Despite these tangible benefits, perhaps the strongest support for the HITECH Act comes from the burgeoning health care information-exchange crisis. To state it bluntly, physicians simply communicate poorly. For example, many primary care physicians fail to receive crucial discharge information from their physician counterparts in the hospital. Patients thus frequently fail to understand medication changes or follow-up plans, lack insight as to when or whom to call for help, and do not have access to vital data after discharge as a result of poor information relay.(4) Even perilous (and preventable) events such as hospital readmissions or medical errors have been associated with a lack of/poor physician communication.(5) In ratifying HITECH, we pin our hopes on technology to streamline these deficits, promote transparency, and homogenize the quality of our documentation. Is this a sensible decision?

Paradoxically, technology may widen the chasm of health information exchange. For instance, almost all major electronic record systems restrict access to providers at a site or health system, insulating accredited caregivers while isolating outsiders. Every electronic health record also employs proprietary technology, alienating providers operating on different platforms despite their common connection to patients. Electronic systems remain provider-oriented and arguably exclude the most important stakeholder, the patient, from data-sharing. Finally, no uniform standard exists to ensure that all electronic health record systems—irrespective of vendor, hospital size, provider, or location—have the ability to share information with each other. In sum, we may stand precariously poised on the edge of an electronic catastrophe.

Is there a way to transform the noble intent of HITECH into a reality that avoids these pitfalls? One revolutionary approach is to take the focus off electronic health records and instead, consider shifting the responsibility of health care communication from providers to patients. The online networking giant, Facebook, provides a conceptual outline for precisely such a schema.

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-- Vineet Chopra, MD, FACP, FHM, Laurence F. McMahon Jr., MD, MPH

This article originally appeared in the June 2011 issue of The American Journal of Medicine.

Cardiovascular Screening with Electrocardiography and Echocardiography in Collegiate Athletes

Current guidelines for pre-participation screening of competitive athletes in the US include a comprehensive history and physical examination. In this study, researchers screened athletes according to the guidelines and used electrocardiography and echocardiography to further screen people who appeared to be at increased risk for heart conditions.

Abstract

Background
Current guidelines for preparticipation screening of competitive athletes in the US include a comprehensive history and physical examination. The objective of this study was to determine the incremental value of electrocardiography and echocardiography added to a screening program consisting of history and physical examination in college athletes.

Methods
Competitive collegiate athletes at a single university underwent prospective collection of medical history, physical examination, 12-lead electrocardiography, and 2-dimensional echocardiography. Electrocardiograms (ECGs) were classified as normal, mildly abnormal, or distinctly abnormal according to previously published criteria. Eligibility for competition was determined using criteria from the 36th Bethesda Conference on Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities.

Results
In 964 consecutive athletes, ECGs were classified as abnormal in 334 (35%), of which 95 (10%) were distinctly abnormal. Distinct ECG abnormalities were more common in men than women (15% vs 6%, P<.001) as well as black compared with white athletes (18% vs 8%, P<.001). Echocardiographic and electrocardiographic findings initially resulted in exclusion of 9 athletes from competition, including 1 for long QT syndrome and 1 for aortic root dilatation; 7 athletes with Wolff-Parkinson-White patterns were ultimately cleared for participation. (Four received further evaluation and treatment, and 3 were determined to not need treatment.) After multivariable adjustment, black race was a statistically significant predictor of distinctly abnormal ECGs (relative risk 1.82, 95% confidence interval, 1.22-2.73; P=.01). Conclusions
Distinctly abnormal ECGs were found in 10% of athletes and were most common in black men. Noninvasive screening using both electrocardiography and echocardiography resulted in identification of 9 athletes with important cardiovascular conditions, 2 of whom were excluded from competition. These findings offer a framework for performing preparticipation screening for competitive collegiate athletes.

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-- Anthony Magalski, MD, Marcia McCoy, RN, MSN, Michael Zabel, MD, Lawrence M. Magee, MD, Joseph Goeke, MD, Michael L. Main, MD, Linda Bunten, RN, BSN, Kimberly J. Reid, MS, Brian M. Ramza, MD, PhD

This article originally appeared in the May 2011 issue of The American Journal of Medicine.

How Is Being the Editor-in-Chief of a Medical Journal like Organizing Games in the Colosseum of Ancient Rome?

A recent article in Smithsonian magazine described the infrastructure and operation of the Colosseum in ancient Rome, as well as the nature of the entertainment furnished in the arena.(1) I have referred to this monthly magazine in previous editorials because it regularly publishes a number of fascinating pieces. This month, I learned something particularly interesting: The Latin title of the person who sponsored the Roman games translates into “the editor.” The editor of the games underwrote the performances financially and usually dictated the types of entertainment displayed. It is common knowledge that many of these spectacles involved bloody events, including battles with wild animals, skirmishes between gladiators, and executions.

I felt a moment of personal irony when comparing my own role as the editor of The American Journal of Medicine (AJM) with that of the ancient Roman editors of the Colosseum. I do not sponsor the journal financially, nor are there bloody events contained within each issue. However, some might argue that a number of our pathologic and dermatologic images verge on gory! Having given some thought to other differences between my own job and that of my Roman predecessors, I have listed 11 tasks performed by editors of medical journals. I suspect that at least some of them also were undertaken by the editors responsible for events in the Colosseum.

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-- Joseph S. Alpert, MD, editor-in-chief, The American Journal of Medicine

This article originally appeared in the June 2011 issue of The American Journal of Medicine.