Clinical Briefs: Diabetes and menstruation; depression and CABG outcomes; valsartan and CHF
January 15, 2002 3 minutes read
Long or Highly Irregular Menstrual Cycles as a Marker for Risk of Type 2 Diabetes Mellitus
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One of the best-studied at-risk groups for type 2 diabetes mellitus (DM-2) is the PIMA Indian women. In this population, as well as women suffering polycystic ovary syndrome, menstrual cycle irregularity (MCI) has been associated with an increased frequency of DM-2. The current study is the first to assess, in a large population, the predictive relationship between MCI and DM-2. Solomon and colleagues report on women in the Nurses Health Study II (n = 101,073). Information collected in this population included cycle length and pattern. Information about weight (pertinent to possible polycystic ovarian disease) and severe acne (suggesting excess androgen stimulation) was also obtained. This population of women is 92% Caucasian, and data were accrued by self-report from study inception (1989) through 1997.
Women with particularly short menstrual cycles (< 21 days) did not differ significantly in DM-2 risk from those with cycle length of 26-31 days. On the other hand, women with cycle length > 40 days had a 2-fold increased risk of developing DM-2, which persisted after adjustment for markers of excess androgen. Solomon et al suggest that women with MCI may benefit from guidance on weight reduction and exercise, to reduce risk of subsequent DM-2.
Solomon CG, et al. JAMA. 2001;286: 2421-2426.
Relation Between Depression After Coronary Artery Bypass Surgery and 12-Month Outcome
Despite the fact that the mechanisms by which depression evokes its detrimental effect are obscure, the ponderous negative effects of depression on outcomes in patients suffering acute cardiac events is consistent. Prospective studies indicate that persons who have depression after MI are 2-4 times more likely to have another event, and more likely to die of cardiac related causes in the ensuing 6-18 months. Such effects are independent of traditionally measured severity-of-illness variables, ie, depression is an independent predictor.
This report studied the association between depression and the composite outcome of: 1) CHF hospitalization; 2) MI; 3) angioplasty; 4) bypass procedure; 5) cardiac arrest; and 6) cardiac death (primary outcome variable = composite of #1-6). Depression was measured by a (modified) US NIMH diagnostic interview performed within a few days after surgery. Patients (n = 309) were followed for 12 months. At entry to the study, 20% of patients met criteria for major depressive disorder.
Depression had a powerful negative effect on outcomes. Almost 3 times as many depressed patients had a cardiac event as those without depression over the 12 months of follow-up. It remains to be determined whether treatment of depression will alter its effect on outcomes.
Connerney I, et al. Lancet. 2001;358: 1766-1771.
A Randomized Trial of Valsartan in CHF
Modulation of the renin-angiotensin-aldosterone (RAA) system for patients with chronic heart failure (CHF) has become an established method for initial management, primarily by means of angiotensin converting enzyme inhibitors (ACE). Limited data have suggested that angiotensin-receptor blockers (ARB) may enjoy some of the same benefits in CHF. Cohn and colleagues studied Class II-IV CHF patients (n = 5010) who were assigned to valsartan 160 mg b.i.d. (VAL) or placebo, in addition to their "background" medications, which could include ACE, diuretics (HCTZ), and beta blockers (BB). Patients were followed for 27 months.
The combined end point of mortality and morbidity was significantly improved by VAL (13% risk reduction), although VAL treatment had no significant effect upon mortality alone. CHF hospitalizations were reduced by over 25% with VAL. Clinical findings of dyspnea, fatigue, edema, and rales were affected more favorably in VAL recipients. One subgroup prompts a cautionary note: the patients who entered the trial on combined ACE/BB treatment experienced a modest worsening of mortality.
Cohn JN, et al. N Engl J Med. 2001; 345:1667-1775.
Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.
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