Clinical Briefs: ACE Inhibitors; Pheochromocytoma; Sexual Dysfunction in Women with Diabetes
May 30, 2002
ACE Inhibitors, Muscle Strength, and Physical Functioning in Older Women
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The use of angiotensin-converting enzyme (ACE) inhibitors has been shown in chronic systolic heart failure (CHF) to reduce mortality, and prevent progression from mild degrees of CHF to more severe disease. Additionally, ACEs have been shown to reduce mortality, stroke, and other vascular end points in persons with previous evidence of vascular disease (ie, adults > 55 with prior stroke, MI, peripheral vascular disease, or diabetes). Whether ACE can be of benefit in persons without CHF or proven vasculopathy was evaluated in this 3-year trial of hypertensive women (n = 641).
Subjects were divided into the categories of continuous ACE users (n = 61), intermittent users (n = 133), never users (n = 146), and "other users," whose hypertension had been controlled either continuously or intermittently with other drugs (n = 301).
Knee extensor muscle strength, walking speed, and overall physical activity was assessed. Mean age of the subjects was 78.9 years. Patients with CHF were excluded from the trial.
Over time, all groups lost some muscle strength, but the continuous ACE lost the least. There was a trend toward continuous ACE use being associated with lesser loss of muscle strength than intermittent ACE use. Walking speed (which has been shown to be predictive of disability and mortality, as well as other end points) also declined less in continuous ACE recipients than any other group.
Potential mechanisms by which ACE could favorably affect these end points include positive effect on myosin heavy chains in muscle, improvements in insulin sensitivity, improved skeletal blood flow due to reduced kinin breakdown, and others.
Onder G, et al. Lancet. 2002;359:926-930.
Diagnosis of Pheochromocytoma—Which Test is Best?
Although a rare cause of hypertension (HTN), pheochromocytoma (PHEO) is ultimately correctable, and the potential devastating consequences of catecholamine excess found with PHEO merits consideration in a variety of clinical settings in which a secondary cause of HTN is suspect. Unfortunately, diagnosis is hampered by both false-negative and false-positive testing methodologies. Lenders and colleagues evaluated a variety of tests for PHEO in 865 patients submitted for PHEO evaluation at 4 referral centers over a 7-year period, of whom ultimately 214 were confirmed to have PHEO.
The tests studied included plasma free metanephrines (P-FMET), plasma catecholamines (P-CAT), urinary catecholamines (U-CAT), urinary total metanephrines (U-TMET), urinary fractionated metanephrines (U-FMET), and urinary vanillylmandelic acid (U-VMA).
The 2 measurements with highest sensitivity for PHEO were P-FMET and U-FMET. Highest specificity was found for U-VMA and U-TMET. Based on this information, Lenders et al conclude that P-MET should be the first test of choice for diagnosis of PHEO. Indeed, they suggest that the practice of ordering multiple diagnostic tests should be eschewed, indicating that the diagnosis of PHEO may be adequately included or excluded by simply using the P-FMET alone.
Lenders JWM, et al. JAMA. 2002;287: 1427-1434.
Sexual Dysfunction in Women with Type 1 Diabetes
The association of diabetes mellitus (DM) with erectile dysfunction is clearly established. Less studied is the relationship between diabetes and female sexual dysfunction (FSD). Enzlin and colleagues evaluated sexual function in 97 diabetic Belgian women using questionnaires to assess psychological adjustment to DM, marital satisfaction, depression, and sexual function. As controls, healthy nondiabetic age-matched women (n = 180) attending an outpatient gynecology clinic responded to the same questionnaire.
Almost twice as many DM women suffered than controls and reported sexual dysfunction (27% vs 15%). Specifically, arousal problems (indicated by poor lubrication) were more frequent, in contrast to disorders of desire, dyspareunia, and orgasm, which were found with equal frequency in the DM and control groups.
The population studied was young (mean age 34), so this prevalence of sexual dysfunction may appear surprising. Additionally, DM women with FSD were found to have a more negative appraisal of their DM, including more problems with emotional adjustment. DM women have a greater burden of FSD than age-matched counterparts. This is the largest study performed to date to compare the frequency of FSD in patients with and without DM.
Enzlin P, et al. Diabetes Care. 2002; 25:672-677.
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