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Updated Stroke Prevention Guidelines

Updated Stroke Prevention Guidelines

The American Heart Association and American Stroke Association (AHA/ASA) have updated guidelines on primary stroke prevention based on comprehensive and timely evidence from clinical investigations and research trials. Recommendations are included for controlling risk factors, using interventional approaches to atherosclerotic disease, and antithrombotic treatments for preventing stroke. The guidelines were published in Stroke and are available for free online at http://stroke.ahajournals.org. “One of the most important changes in the AHA/ASA guidelines is that newer anticoagulants can be used as alternatives to warfarin to prevent stroke in patients with atrial fibrillation (AF),” says James F. Meschia, MD, FAHA, who chaired the AHA/ASA committee that developed the recommendations. The guidelines note that although some of the new AF drugs are more expensive, they require less ongoing monitoring and therefore represent reasonable options for patients. Another key recommendation from the guidelines is that clinicians are urged to use of statins, along with diet and exercise, to help lower the stroke risk in patients at high risk for experiencing a stroke within the next 10 years. “In addition, the CHA2DS2-VASc is recommended for stratifying the risk for stroke,” says Dr. Meschia. “Patients with a score of 0 on the CHA2DS2-VASc do not require anticoagulants, but those with a score of 2 or higher should receive these therapies.” He adds that patients with a score of 1 on CHA2DS2-VASc can be considered for anticoagulants.   Women & Stroke According to the AHA/ASA, women have higher stroke risks if they are pregnant, use oral contraceptives, use hormone replacement therapy, have migraines, and/or have depression. The guidelines recognize the different risk factors women face throughout their...
Systolic Hypertension & Cardiovascular Mortality

Systolic Hypertension & Cardiovascular Mortality

Studies have shown that isolated systolic hypertension (ISH)—defined as having a systolic blood pressure (BP) of 140 mm Hg or higher with a diastolic BP less than 90 mm Hg—is associated with elevated risks for cardiovascular disease (CVD) in older adults. “There has been a sense among clinicians that ISH is a benign condition in younger people,” explains Donald M. Lloyd-Jones, MD, ScM. “This had led some experts to label ISH as pseudo-hypertension, but the data to support this belief are limited.”   A Look at Younger Patients Few studies have looked at ISH in younger patients, despite research suggesting that its prevalence has increased in younger and middle-aged adults in recent years. For a study published in the Journal of the American College of Cardiology, Dr. Lloyd-Jones and colleagues assessed the risk for CVD in 27,000 patients aged 18 to 49 who did not have diagnosed coronary heart disease and were not taking antihypertensive therapy when they were assessed at baseline. Participants in the study were classified into one of the following groups: Optimal-normal BP (systolic BP <130 mm Hg, diastolic BP <85 mm Hg). High-normal BP (systolic BP 130 to 139, diastolic BP 85 to 89 mm Hg). ISH. Isolated diastolic hypertension (systolic BP <140 mm Hg, diastolic BP ≥90 mm Hg). Systolic and diastolic hypertension (systolic BP ≥140 mm Hg, diastolic BP ≥90 mm Hg). With access to the Chicago Heart Association Study database and linkage to the National Death Index, the study team was able to assess follow-up data on the cause of death among participants as well as 35-year outcomes, with an average follow-up...
The Current State of Pediatric Pulmonary Hypertension

The Current State of Pediatric Pulmonary Hypertension

Research has shown that pulmonary hypertension is associated with substantial morbidity and mortality in children. Registry data from the United Kingdom and the Netherlands estimate an incidence of idiopathic pulmonary hypertension of 0.48 to 0.70 cases per million, respectively. However, such data on pediatric pulmonary hypertension remain unknown in the United States. Studies assessing the inpatient care of pediatric pulmonary hypertension in the U.S. have been small or focused on select subgroups of patients. Reviewing the Data To determine trends in volume, demographics, procedures performed during admission, and resource use, Bryan Maxwell, MD, MPH, Melanie Nies, MD, and colleagues examined national data on hospitalizations among pediatric patients with pulmonary hypertension. The study, published in Pediatrics, reviewed data from 1997 to 2012 in the Kids’ Inpatient Database, the largest publicly available database of inpatient pediatric care in the United States, according to Dr. Nies. Beginning in 1997, the database has released discharge data every 3 years from thousands of hospitals throughout the U.S. Overall, children with pulmonary hypertension accounted for 0.13% of 43 million pediatric hospitalizations included in the registry during the study period. Discharges for pediatric pulmonary hypertension doubled from 1997 to 2012. Cumulative, inflation-adjusted national hospital charges associated with pediatric pulmonary hypertension hospitalizations increased from $926 million in 1997 to $3.12 billion in 2012. “It is important to note that although all-cause, in-hospital mortality associated with the condition remains high, it decreased from 11.3% of hospitalizations in 1997 to 5.9% in 2012,” Dr. Nies says. The study investigators also found a shift in the type of children who accounted for the majority of pediatric pulmonary hypertension cases. “Children...
CME: Treatment-Resistant Hypertension: Assessing Predictors & Outcomes

CME: Treatment-Resistant Hypertension: Assessing Predictors & Outcomes

“The topic of treatment-resistant HTN has gained attention in recent years,” says Rhonda M. Cooper-DeHoff, PharmD, MS, FAHA, FACC. “The condition increases long-term risk for poor outcomes, regardless of whether or not HTN is controlled or uncontrolled. Unfortunately, we’re lacking important data on the long-term effects of treatment-resistant HTN.” Coronary artery disease (CAD) is among the leading causes of mortality, and treatment-resistant HTN is more common in patients with CAD than without CAD. Little is known, however, about the impact that treatment-resistant HTN has on cardiovascular outcomes in patients with CAD. Such data may inform clinicians on strategies to aggressively manage risk factors. Identifying Predictors & Impact In the Journal of Hypertension, Dr. Cooper-DeHoff and colleagues published a study that described the prevalence, predictors, and impact on adverse cardiovascular outcomes of resistant HTN among patients with CAD and HTN. More than 17,000 study participants were divided into three groups according to achieved BP: 1) controlled (BP<140/90 mm Hg on three or fewer drugs); 2) uncontrolled (BP≥140/90 mm Hg on two or fewer drugs); or 3) resistant (BP≥140/90 mm Hg on three drugs or any patient on at least four drugs). “We found that resistant HTN occurred in 38% of patients with CAD and HTN,” says Dr. Cooper-DeHoff. “Those with resistant HTN were at increased risk for having poorer outcomes.” Several characteristics were associated with an increased risk of resistant HTN, including a history of heart failure, diabetes, and renal insufficiency, among others (Figure 1). Overall, 13 independent predictors of resistant HTN were identified. Many of these characteristics can be obtained noninvasively and help clinicians recognize these patients in the clinic. “The prevalence...
An Update on Fibromuscular Dysplasia

An Update on Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) has been defined as a non-atherosclerotic, non-inflammatory vascular disease that can result in arterial stenosis, occlusions, aneurysms, or dissections. Although the cause of FMD and its prevalence in the general population are unknown, research has shown that it has been reported in virtually every arterial bed. Most commonly, FMD affects the renal and extracranial carotid and vertebral arteries. When the renal artery is involved, the most frequent finding is hypertension. Carotid or vertebral artery FMD may lead to dizziness, pulsatile tinnitus, transient ischemic attack (TIA), or stroke. According to Jeffrey W. Olin, DO, FACC, FAHA, there is an average delay of 4 to 9 years from the time of the first symptom or sign to a diagnosis of FMD. “Many consider this disease rare, but in reality, the diagnosis is often overlooked,” he says. “Thus, it’s not considered in a differential diagnosis. In addition, FMD is poorly understood by many healthcare providers. Many of the signs and symptoms are non-specific, which in turn can lead clinicians down the wrong diagnostic pathway.” He notes that a delayed diagnosis can impair quality of life and result in poor outcomes. In 2014, the American Heart Association (AHA) released a scientific statement on FMD that addressed the state of the science and critical unanswered questions. “Over the last several years, we have learned that FMD is more common than previously thought,” says Dr. Olin, who chaired the AHA writing committee that developed the scientific statement. “FMD is frequently being discovered incidentally while imaging is performed for other reasons in asymptomatic patients without classic risk factors for atherosclerosis. The clinical manifestations...
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