Statins and cognitive function: an updated review.

Ischemic heart disease remains the leading cause of death in the USA. Statins have substantially contributed to the decline in mortality due to heart disease. Historically, statins are hypothesized to be neuroprotective and beneficial in dementia, but recent reports have suggested an association with transient cognitive decline. We have critically appraised the relationship between statins and cognitive function in this review. Most of the data are observational and reported a protective effect of statins on dementia and Alzheimer's disease in patients with normal cognition at baseline. Few studies, including two randomized control trials, were unable to find a statistically significant decrease in the risk or improvement in patients with established dementia or decline in cognitive function with statin use. As more randomized control trials are required to definitively settle this, cardiovascular benefits of statins must be weighed against the risks of cognitive decline on an individual basis.

Health-related quality of life after transcatheter or surgical aortic valve replacement in high-risk patients with severe aortic stenosis: an updated review of literature.

Recent trials have highlighted the comparable mortality benefits and durability of the results for patients with severe aortic stenosis (AS) and high surgical risk managed with either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (AVR). Various national guidelines and international regulatory bodies have approved TAVR, thereby leading to potential wide usage and dissemination of this technique worldwide. Quality-of-life outcomes, in spite of being an important measure of success and acceptability of the procedure, have not been publicized as extensively. For high risk patients with severe AS, implementation of TAVR has resulted in comparable survival, but different and novel adverse events compared with AVR. We present an updated review focusing on the quality-of-life outcomes and issues with this new and important procedural approach.

Patient satisfaction and resident postgraduate year status.

PURPOSE: Patient satisfaction has been recognized as an important variable affecting healthcare behavior. However, there are limited data on the relationship between doctor post-graduate year (PGY) status and patient satisfaction with provider interpersonal skills and humanistic qualities. The authors aims to assess this relationship using an American Board of Internal Medicine (ABIM) questionnaire. DESIGN/METHODOLOGY/APPROACH: Participants were: patients attending a primary care clinic at a large urban academic hospital; and physicians treating them. The survey questionnaire was the ABIM patient satisfaction instrument; ten questions pertaining to humanistic qualities and communication skills with responses from poor to excellent. Mann Whitney U test and multi-variable logistic regression analyses were used to explore score differences by PGY level. FINDINGS: The postgraduate year one (PGY1) had higher patient-satisfaction levels compared to PGY2/PGY3 residents. The PGY1 level residents were more likely to score in the 90th percentile and this remained constant even after adjusting for confounders. RESEARCH LIMITATIONS/IMPLICATIONS: The research was a single-center study and may have been subject to confounding factors such as patient personality types and a survey ceiling effect. The survey's cross-sectional nature may also be a potential limitation. Practical implications - Patient satisfaction varies significantly with PGY status. Though clinical skills may improve with increasing experience, findings imply that interpersonal and humanistic qualities may deteriorate. ORIGINALITY/VALUE: The study is the first to assess patient satisfaction with PGY status and provides evidence that advanced trainees may need support to keep their communication skills and humanistic qualities from deteriorating as stressors increase to ensure optimal patient satisfaction.

Association of hypertension and bone mineral density in an elderly African American female population.

BACKGROUND: Recent studies have shown that hypertension is inversely correlated with bone mineral density (BMD) as determined by dual energy x-ray absorptiometery (DXA) in different ethnic groups. But in most published studies, either the sample size was small or the study was limited by different measurement methods. These limitations leave this association controversial and inconclusive. The current study utilizes a sample of African American females referred for clinical screening of osteoporosis in our center to find out if any association of high blood pressure and BMD in this ethnic group exists. The secondary endpoint was to determine the effect of thiazide diuretics on BMD of the elderly African American females because, theoretically, thiazides are considered to have a positive impact on BMD. METHODS: In this retrospective, cross-sectional study, 10 years of data were reviewed from 1113 medical records of African American females aged 65 years and older whose BMD values were measured by DXA at the lumbar spine (L1-L4) and both femoral necks (the standard sites for BMD determination) along with their T scores and Z scores (used to determine osteopenia vs osteoporosis). Our exclusion criteria included patients who: (1) were current smokers, (2) had a previous oophorectomy, (3) had a history of corticosteroid use, (4) had a history of biphosphonate use, (5) were on hormone replacement therapy, and (6) were diabetic and taking either pioglitazones or roziglitazones. A total of 148 patients were excluded from the analysis due to either incomplete data or exclusion criteria. The remaining sample was then divided into 2 groups based on their hypertensive status. For the subanalysis, the hypertensive group was further divided into 2 additional groups based on their thiazide usage. RESULTS: We had complete data on 965 participants, of which 631 (65.3%) had a history of hypertension and 334 (34.7%) did not. Out of 631 hypertensive patients, 173 were found to be using thiazide diuretics as antihypertensive medication, while 458 were without thiazide diurectic use. The proportion of patients with both osteopenia and osteoporosis was similar in those with and without hypertension (50% vs 50%, p = .95 for osteopenia; 18% vs 19%, p = .95 for osteoporosis). There was no significant difference between the BMD at the lumbar spine, and right and left femoral necks between patients with and without hypertension. This lack of association held true when comparing the mean T scores and Z scores at the above sites. Within patients with a history of hypertension, there were no significant differences in the BMD, T score or Z score at any site with and without a history of thiazide diuretic use. CONCLUSION: Hypertension in elderly African American females aged at least 65 years was not found to be correlated with low BMD at either the lumbar spine (L1-L4) or both femoral necks when confounding factors were taken into consideration. Mean BMD of the hypertensive cohort taking thiazide diuretics was found lower at the lumbar spine as compared to the hypertensive patients not taking thiazide diuretics.

Dexmedetomidine use in the setting of cocaine-induced hypertensive emergency and aortic dissection: a novel indication.

Aortic dissection is a potentially fatal but rare disease characterized by an aortic intimal tear with blood passing into the media creating a false lumen and with resultant high mortality depending on the location of dissection if not aggressively treated. Cocaine users are known to have a higher incidence of aortic dissection. We report here aortic dissection in a patient with cocaine abuse which did not respond to traditional medication regimes used currently in this setting. Worth mentioning is the use of an alpha-2 receptor selective agonist named Dexmedetomidine as a treatment modality to control hypertension in this patient, which is approved only for sedation of intubated and mechanically ventilated patients in the intensive care settings and for sedation during invasive procedures. This paper illustrates the practical beneficial role of Dexmedetomidine in controling blood pressure in the settings of cocaine-induced sympathetic surge when other treatment modalities fail.

Effect of adding nitroglycerin to early diuretic therapy on the morbidity and mortality of patients with chronic kidney disease presenting with acute decompensated heart failure.

BACKGROUND: Loop diuretics are considered first-line therapy for patients with acute decompensated heart failure (ADHF). Adding nitroglycerin (NTG) to diuretic therapy for alleviation of acute shortness of breath has been advocated in our institution. We evaluated the benefits of adding NTG to diuretics in the emergency department for patients with ADHF and chronic kidney disease (CKD). METHODS: 430 consecutive patients with ADHF who were admitted with a chief complaint of dyspnea were included in this retrospective study. Patients were divided into 3 groups. Group A patients were treated with neither diuretics nor NTG; Group B patients were treated with diuretics only; and Group C patients were treated with both diuretics and NTG. Estimated glomerular filtration rate (GFR) was calculated according to the Cockcroft-Gault formula. Follow-up was 36 ± 9 (mean ± standard deviation [SD]) months. Primary endpoints were readmission rate at 30 days and mortality at 24 months. RESULTS: 430 patients were included in this study (42% men; age, 69 ± 14 [mean ± SD] years); mean New York Heart Association class was 2.4 ± 0.7 (mean ± SD) and mean ejection fraction was 28% ± 17% (mean ± SD). Group A included 257 (59%) patients, Group B had 127 (29%) patients, and Group C had 46 (11%) patients. Group C patients were older (mean age, 72 ± 13 years) with lower body mass index (26 ± 7 kg/m2), lower estimated GFR (55.8 ± 38 mL/min per 1.73 m2), higher B-type natriuretic peptide levels (1112 ± 876 pg/mL; P = nonsignificant [NS]), and higher systolic and diastolic blood pressures on admission (P = 0.001). The primary endpoint was assessed as a composite of all-cause mortality and ADHF readmission seen in 143 (56%) Group A patients, 68 (53%) Group B patients, and 22 (48%) Group C patients (P = NS). At 30 days there were 53 (12%) readmissions--26 in Group A, 20 in Group B, and 7 in Group C (P = NS). However, survival at 24 months was higher in Group C (87%) compared with Groups A (79%) and B (82%) (P = 0.002). Using the Cox proportional-hazards regression module, early administration of NTG and Lasix (95% confidence interval [CI], 1.06-1.62; P = 0.01) followed by CKD stage (95% CI, 1.00-1.35; P = 0.04) were the only predictors for survival. CONCLUSION: There is a role for early administration of NTG in addition to diuretic therapy in patients admitted to the emergency department with ADHF, with resultant decreased length of stay and a trend toward a decrease in the composite endpoint of all-cause mortality and ADHF readmission. The mortality benefit at 2 years reported in our study is thought-provoking and raises a premise to be proven in randomized clinical trials.

The association of the Friesinger score and pulse pressure in an urban South Asian patient population: pulse pressure, an independent predictor of coronary artery disease.

Increase in pulse pressure has been shown to be predisposing factor for Coronary Artery Disease (CAD) in diverse patient populations but its relationship with the severity of CAD, particularly in the South Asians immigrant population of United States has not been demonstrated. We performed a single-center, cross-sectional study. Pulse pressure was calculated by the difference between the systolic and diastolic brachial blood pressures, and the Friesinger score (FS) was used to quantify the severity of CAD with the score of 5 used as a cutoff for extensive disease. We also sought to assess the correlation between the Friesinger score and the 10-year cardiovascular event (CVD) risk as calculated by the Framingham score. Odds ratios and 95% confidence intervals for the associations between explanatory variables and a high Friesinger score were estimated using multivariate logistic regression models. P values below .05 were considered to be statistically significant. Statistical analysis was performed using STATA version 10 software package (College Station, TX). The mean pulse pressure was significantly higher in participants with an FS of > or =5 compared with participants with an FS of <5 (63 vs. 46 mm Hg; P = .004). In univariate analysis, a pulse pressure > or =40 mm Hg was associated with a five-fold increased odds of a higher FS compared with a pulse pressure <40 mm Hg (P = .039), which was unchanged in multivariate analysis. In multivariate analysis, even after adjustment for presence of hypertension, a 10 mm Hg increase in pulse pressure was associated with a 1.97-fold increased odds of a higher FS (95% CI 1.22-3.71, P = .009). The mean Framingham score was higher in participants with a higher FS, but this difference was not significant (32.7 vs. 20.3; P = .1139). Our study demonstrates that pulse pressure, a well-established marker of vascular health, is a significant independent predictor of the severity of CAD as assessed by coronary angiography in South Asians.