Clinical Briefs: Spironolactone for refractory hypertension; amoxicillin for purulent rhinorrhea; exercise testing in elderly men
June 15, 2002
The Role of Spironolactone in the Treatment of Patients with Refractory Hypertension
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Control of hypertension (HTN) remains an important public health goal, since JNC VI reports indicate that as few as 27% of hypertensive patients are on treatment and under control. Part of the reason for this level of inadequate control is the difficulty of achieving normotension, despite earnest pharmacologic interventions. Spironolactone (SPR) might be rightfully characterized as an "older" antihypertensive agent, since it was first approved for the treatment of hypertension in 1983. Except for its role in management of heart failure, little recent attention has been paid to its potential role for management of any other cardiovascular maladies. This trial incorporated SPR among patients defined as "refractory;" persons who maintained blood pressure > 140/90 despite optimal doses of at least 2 antihypertensive agents.
SPR was dosed at 1 mg/kg/d orally, once daily; once blood pressure control was achieved, dosing was reduced to 50 mg/d or less, as needed to control blood pressure. Patients (n = 25) were seen at 1 and 3 months after initiation of SPR. SPR was added to whatever baseline therapy the patient was receiving, except that patients treated with ACE inhibitors had SPR substituted for their ACE.
By 1 month of SPR treatment, 23/25 patients were controlled. By 3 months, all were controlled. Long-term follow-up of these patients went on as long as 2 years, with all SPR patients maintained on low-dose SPR. Only 2 patients were SPR intolerant (1 gynecomastia, 1 impotence). Possibly, some of these patients suffered heretofore undiagnosed hyperaldosteronism. Be that as it may, the observation that a substantial portion of resistant HTN patients might benefit from this inexpensive, well-tolerated medication, is encouraging.
Ouzan J, et al. Am J Hypertens. 2002; 15:333-339.
Does Amoxicillin Improve Outcomes in Patients with Purulent Rhinorrhea?
Uncertainty among clinicians about which patients presenting with upper respiratory tract infections (URI) might benefit from antibiotic treatment may result in over-prescribing. Studies that address the issue of antibiotic efficacy in URI may not mirror clinical practice settings, since often they include imaging or laboratory studies as part of the study that are not available, or not used, in typical clinical practice. To address a commonplace clinical scenario seen in primary care, De Sutter and colleagues studied the effect of antibiotic treatment, specifically amoxicillin (AMX), on patients presenting with URI manifest with purulent rhinorrhea (n = 416).
Subjects were randomized to receive either AMX 500 mg t.i.d. or placebo for 10 days.
Though there was a trend toward greater success, defined as no symptoms or very mild symptoms in persons who received AMX, this effect was not statistically significant. The presence of purulent rhinorrhea, a secondary outcome, disappeared more quickly in persons who received AMX than placebo, but this effect was not sufficient to effect overall recovery. The only other measurable difference between AMX and placebo was the greater frequency of diarrhea with the former. De Sutter et al conclude that patients presenting with purulent rhinorrhea do not gain from the administration of AMX.
De Sutter AI, et al. J Fam Pract. 2002; 51:317-323.
The Prognostic Value of Exercise Testing in Elderly Men
Other than for predicting exercise capacity, the role of exercise treadmill testing (ETT) in asymptomatic men remains to be established. Additionally, there are little data to evaluate the prognostic value of ETT in elderly men, whose exercise capacity, and response to exercise, may differ from younger men. This study evaluated a population of men referred to VA hospitals in California (n = 3974) for ETT. Reasons for referral were not detailed in this report, but patients with CHF, MI, or previous coronary bypass were excluded from analysis.
Of the commonplace cardiovascular risk factors (ie, hypertension, smoking, obesity, family history), only hypertension was more commonplace among older men. Using either the US Air Force School of Aerospace Medicine protocol, or an individualized ramp treadmill protocol, all subjects underwent symptom-limited ETT.
As intuition would predict, elderly subjects (age > 65 years) were not able to achieve an equal workload to that attained by younger men (< 65 years). Subjects were followed for 6 years. During this period, mortality in the elderly group was much greater than the younger group (23% vs 10%). The data revealed that the best prognostic factor related to future mortality was METs achieved on ETT: for each 1 MET increase achieved on ETT, there was an associated 11% reduction in mortality.
Spin JM, et al. Am J Med. 2002;112: 453-459.
Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.
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