Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Pulse Pressure and Risk of New-Onset Atrial Fibrillation
Risk factors for atrial fibrillation (AF) most prominently include age, hypertension, diabetes, valvular disease, and heart failure. It has been theorized that the progressive increase in aortic stiffness that occurs with age, which leads to increased vascular resistance, greater cardiac workload, and ventricular hypertrophy, might be a fundamental underlying mechanism for development of AF. Pulse pressure (systolic BP minus diastolic BP) reflects vascular stiffness. Using data from the Framingham Heart Study, Mitchell et al studied the relationship between pulse pressure (PSP) and incidence of AF.
Over a 20-year period of observation, 698 participants developed AF. The incidence of AF in the highest quintile of PSP (> 61 mmHg) was more than 4-fold greater than the lowest PSP quartile (< 40 mm Hg).
Even after adjusting for multiple confounding risk factors (eg, smoking, diabetes, LVH, HTN), for every 20 mmHg increment in pulse pressure, there was a 26% increase in risk of AF. PSP appears to be a prominent risk factor for AF; whether treatment that reduces PSP will reduce endpoints remains to be determined.
Mitchell GF, et al. JAMA. 2007;297(7):709-715.
Challenges to Stages of Grief Theory
The most well-accepted model for stages of grief (SOG) associated with bereavement or terminal illness describes the following 5-step sequence: denial/dissociation/isolation, anger, bargaining, depression, and acceptance. Not all experts confirm that this sequence is consistent. For instance, several reports have demonstrated that depression is not always part of the bereavement process. Defining boundaries for the normal grief process helps to define those who have not resolved grief in a healthful fashion; additionally, it may identify persons who require intervention due to failure to progress through normal SOG.
The Yale Bereavement Study invited Connecticut residents identified as suffering bereavement due to loss of a loved one (n = 233), and collected data up to 24 months post-loss. Interviewers periodically assessed and scored levels of yearning, disbelief, anger, and acceptance of death during this interval.
Contrary to current theory, instead of disbelief being the most common initial stage, acceptance was. A "map" of bereavement indicators derived from this population shows that yearning, anger, and depression peak sequentially at 4, 6, and 8 months, respectively and progress to resolution by 24 months. The authors suggest that the DSM-IV may need revision with respect to normal patterns of bereavement. Clinicians may wish to use this metric for progression of bereavement to help identify patients whose healing process is not advancing in a healthy fashion.
Maciejewski PK, et al. JAMA. 2007;297:716-723.
EKG abnormalities in Asymptomatic Women: Association with CV Events
Data from mostly-male populations indicates that EKG abnormalities in asymptomatic persons are associated with adverse cardiovascular outcomes. The Women's Health Initiative (WHI) has provided a large population of healthy women amongst whom the association between EKG abnormalities and subsequent CV health can be studied. Denes, et al provide data on women from the estrogen-and-progestogen replacement arm of the WHI (women with uterus intact, n = 14,749, of whom half received placebo).
Women participating in the WHI were free of known CHD at baseline when their initial EKG was obtained. Followup data was obtained every six months, as well as another EKG at years 3 and 6.
Abnormalities on EKG were categorized as "minor" or "major" according to criteria from the Pooling Project, a national US study. Minor abnormalities included such findings as 1st or 2nd degree heart block, or left atrial enlargement; major abnormalities included such findings as atrial fibrillation, LBBB, or LVH with ST segment abnormalities. At baseline, 66% of women had a normal EKG, 27.8% had minor abnormalities, and 6.2% had major abnormalities.
Women with minor EKG abnormalities at baseline had a 55% relative risk increase of incident CHD compared to women who did not have abnormalities. Incident CHD was increased 3-fold in women with major abnormalities at baseline.
Based upon this data, clinicians may wish to factor EKG abnormalities into their risk stratification scheme for asymptomatic women.
Denes P, et al. JAMA. 2007;297:978-985.
Risk factors for atrial fibrillation (AF) most prominently include age, hypertension, diabetes, valvular disease, and heart failure.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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