Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for Sucampo Pharmaceuticals, Takeda, Boehringer Ingelheim; and is a consultant and on the speaker's bureau for Novo Nordisk, Lilly, Daiichi Sankyo, Forest Pharmaceuticals, Cephalon, Novartis, and Sanofi Aventis.
Exercise improves QOL in CHF patients
Source: Flynn KE, et al. Effects of exercise training on health status in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 2009;301:1451-1459.
Patients with chronic heart failure (CHF) report progressively worse dyspnea with exercise, ranging from Class I NYHA (symptoms only present with strenuous exercise) to Class IV NYHA (symptoms present with any activity, even at rest). Such exertional dyspnea provides disincentive for exercise, and often leads to deconditioning, thereby worsening ability to participate fully in activities of daily living. In the past, there has been some concern that exercise for CHF patients might lead to more adverse events.
Flynn et al randomized patients with systolic CHF (n = 2331), all of whom had an ejection fraction < 35%, to an intensive supervised exercise training program (EXE) vs usual care (USU). The intensive intervention consisted of supervised aerobic exercise training for 36 sessions, at 60-70% of heart rate reserve, three times weekly; subjects then underwent home-based training 5 times per week. The primary outcome was the score on the Kansas City Cardiomyopathy Questionnaire (KCCQ), a validated, heart failure-specific metric. KCCQ scores were obtained quarterly for 1 year, and then annually for an additional 3 years.
KCCQ scores were statistically superior in the EXE group as early as 3 months, and stayed that way through the remainder of the trial. Aerobic exercise training improves the quality of life and activity scores for persons with CHF.
Balloon kyphoplasty for vertebral fractures
Source: Wardlaw D, et al. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): A randomised controlled trial. Lancet 2009;373:1016-1024.
Vertebral fracture (VFX) is the most common complication of osteoporosis. Although often asymptomatic, VFX can cause pain, deformity, and loss of function. Until recently, treatment for VFX was generally conservative, consisting of pain medication, prevention of further osteoporosis, and physical therapy. Balloon kyphoplasty (BKY) is a minimally invasive technique that has been shown to restore function and relieve pain. The procedure is brief (typically < 1 hour), can be done on an inpatient or outpatient basis, and requires minimum down time post-intervention (often ≤ 48 hours).
Wardlaw et al performed a controlled trial comparing BKY with conservative care for patients with VFX (n = 266). The primary outcome was the physical function component of the SF-36 quality-of-life scale over a 1-month interval from the time of intervention.
In the BKY group, the SF-36 score improved by 7.2 points vs 2.0 points in the conservative care group. There was no difference in adverse events between the groups.
Kyphoplasty is a minimally invasive procedure that provides prompt relief of pain, restoration of structural integrity, and improvements in function, with very favorable tolerability. Clinicians should consider BKY a viable option in patients with acute osteoporotic VFX.
CBT for anxiety in older adults
Source: Stanley MA, et al. Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: A randomized clinical trial. JAMA 2009;301:1460-1467.
The prevalence of generalized anxiety disorder (GAD) in older adults is as high as 11% in primary care settings. GAD can often be successfully treated with antidepressants and or benzodiazepines, but such interventions can also be associated with adverse effects and cost. The efficacy of cognitive behavior therapy (CBT) for late-life GAD has not been well established.
Stanley et al enrolled 134 adults (mean, age 70) with GAD in a randomized trial comparing CBT with usual care (USU) in a population of patients attending University of Texas Clinics in the greater Houston area. The primary outcomes of the study were intensity of worry and overall GAD severity.
The CBT intervention was administered in 10-12 sessions over 3 months. CBT intervention included multiple components: motivational interviewing, relaxation training, cognitive therapy, problem-solving skills, and sleep management. The USU group received biweekly phone calls to provide support and offer consultation if symptoms worsened. At baseline, similar numbers of persons in both groups were receiving antidepressants (31-34%) and/or anxiolytics (17%).
For both primary and secondary outcomes, CBT was superior to USU. Benefits of CBT were seen as early as 3 months, and persisted at 15-month follow-up. CBT has been shown to provide outcomes improvement in older adults with GAD.
Patients with chronic heart failure (CHF) report progressively worse dyspnea with exercise, ranging from Class I NYHA (symptoms only present with strenuous exercise) to Class IV NYHA (symptoms present with any activity, even at rest).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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