Clinical Briefs
By Louis Kuritzky, MD
White-Coat HTN
White-coat hypertension (WC-HTN) is defined as elevated blood pressure (BP) when measured in the clinical office setting, which is not confirmed in other settings, eg, home BP monitoring or ambulatory BP monitoring (ABPM). To date, most evidence suggests that WC-HTN, unless associated with target-organ damage, does not require pharmacologic intervention. WC-HTN is perhaps simplistically attributed to the catecholamine impact some persons experience when visiting a clinician's office, however this attribution is imperfect, since it is likely that many, if not most persons have some catechol exaggeration attendant to physician visits. It is poorly established whether WC-HTN patients actually differ from patients with essential HTN as far as activity of the autonomic nervous system goes. Autonomic regulation is commonly measured by assessment of heart rate variability (HRV). An earlier small study of HRV had discerned that WC-HTN does not share the same autonomic imbalance as HTN, supporting the hypothesis that WC-HTN may be more 'benign' than HTN.
Neumann et al studied a population of untreated adult men (n = 120) who had undergone ABPM as well as clinic BP measurement and were then classified as either hypertensive, normotensive, or WC-HTN. HRV was used to assess cardiac autonomic status.
Calculating HRV requires a complex formula called spectral analysis, which can be used to assess sympathetic activity, parasympathetic activity, and the ratio of the two. HTN is characterized by increased sympathetic tone, decreased parasympathetic tone, and a corresponding increased sympathetic/parasympathetic ratio.
In this study, WC-HTN subjects demonstrated lowered parasympathetic tone and an increased sympathetic/parasympathetic ratio. These data will provide fuel for the continued controversy over whether WC-HTN is truly a benign disorder. n Neumann SA, et al. Am J Hypertens. 2005;18(5 pt. 1):584-588.
Make Diabetics Walk
No clinician doubts that exercise is beneficial to patients, and that lack of exercise contributes directly to a diverse array of consequences. Amongst diabetics, vascular end points remain the most burdensome of all medical maladies. Despite the common wisdom of exercise's benefits, there is insufficient data to confirm and quantify the impact of exercise upon outcomes in diabetic patients, and hence establish therapeutic exercise goals.
Di Loreto and colleagues studied a population of adult type 2 diabetics (DM2) in Italy. Subjects (n = 179) did not differ in weekly exercise energy expenditure at baseline, and all were given personal instruction about the importance of regular physical activity. The exercise target was at least 10 metabolic equivalents (METs)/h/week achieved through moderate intensity exercise (3-6 METS); this is approximately equivalent to current recommendations which suggest at least 30 minutes of moderate intensity activity most days of the week. At 2 years, subjects had varying levels of compliance with their encouragement to engage in exercise, allowing for their stratification into 6 levels, ranging from no increase from baseline in weekly activity to 37.5 METs/h/week increase.
As you probably anticipated, the 2 lowest tiers (minimum change in activity) enjoyed no favorable changes in BP, lipids, or Framingham CHD risk score, but the other groups did. There was a linear relationship between incremental increase in activity and favorable effects upon cardiovascular risk factors. Additionally, per capita health expenditures amongst those who became more physically active were substantially less than sedentary folks. Post-hoc analysis showed that the threshold for impacting cardiovascular risk factors was 10 METs/hr/week or greater. Maximum benefit was seen at 27 METs/hr/week, which corresponds to a 3-mile daily walk (either 1 hour/day at 3 mph or 45 minutes/day at 4 mph).
Di Loreto C, et al. Diabetes Care. 2005;28:1295-1302.
Treatment of Complicated Grief
Complicated grief is not a specific diagnosis listed in the DSM-IV. Nonetheless, clinicians are commonly faced with patients who suffer grief syndromes that do not follow a typical course of recovery, which might be termed complicated grief. When assessed 6 months or more after an important loss (eg, death of a spouse), it has 4 primary characteristics: disbelief that the death has actually occurred, anger/bitterness, recurrent episodes of painful emotions, and preoccupation by thoughts of the loved one's death. Complicated grief is in some ways similar to post-traumatic stress disorder.
Complicated grief treatment (CGT) was compared to traditional interpersonal psychotherapy (IPT) in a study of 95 men and women. CGT consisted of cognitive-behavioral therapy-based techniques that are often used in management of PTSD trauma-related symptoms in combination with IPT, vs IPT alone.
Both interventions provided symptom improvement over a 19-week study period. CGT was superior to IPT both in number of responders (51% vs 28%) and time to response. Shear K, et al. JAMA. 2005;293:2601-2608.
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