Twenty-four-hour ambulatory blood pressure monitoring in very elderly patients: Comparison of in-hospital versus home follow-up results.

Elevated blood pressure (BP) is frequently diagnosed in very elderly hospitalized patients. Accurate diagnosis of hypertension is challenging in the hospital environment, due to the "white coat effect," and both overtreatment and undertreatment can adversely affect clinical outcome. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has the potential to avoid the "white coat effect" and accurately guide the management of hypertension. However, effects of the hospital environment on ABPM are unknown in the very elderly. We set out to enroll 45 patients, age ≥70 years, with elevated conventional BP during hospitalization in this observational study. It was prespecified by protocol to assess initially the difference between 24-hour BP during hospital-admission and home follow-up. Subsequent analysis should investigate the change in anxiety (Hospital Anxiety and Depression Scale-A [HADS-A]) after discharge, the correlation with change in 24-hour BP after discharge, and the prevalence of orthostatic hypertension. Thirty-one patients were included in the final analysis (age 83.5 ±â€Š4.4 years; 71% female). Twenty-four-hour BP decreased significantly after hospital discharge (systolic from 133.5 ±â€Š15.6 to 126.2 ±â€Š14.4 mm Hg [millimeter of mercury], P = .008; diastolic from 71.0 ±â€Š9.0 to 68.3 ±â€Š8.6 mm Hg, P = .046). Anxiety level (HADS-A) decreased significantly after discharge, from 7.5 (interquartile range [IQR]: 4.0-13.8) to 5.0 (IQR: 4.0-8.0, P = .012). The change in anxiety was a predictor of change in systolic BP after discharge (F[1,20] = 5.9, P = .025). Sixty-one percent of the patients had significant orthostatic hypotension during hospital stay. In conclusion, 24-hour BP in very elderly patients is lower in the home environment than during hospitalization. This phenomenon seems to be directly linked to a lower anxiety-level at home. Reassessing hypertension at home may decrease the need for (intensified) antihypertensive medical therapy in a substantial number of patients. This is particularly important in the very elderly, who have a high prevalence of symptomatic and asymptomatic orthostatic hypotension, making them prone to hazardous effects of antihypertensive therapy.

Statins and the risk of cancer after heart transplantation.

BACKGROUND: Although newer immunosuppressive agents, such as mTOR (mammalian target of rapamycin) inhibitors, have lowered the occurrence of malignancies after transplantation, cancer is still a leading cause of death late after heart transplantation. Statins may have an impact on clinical outcomes beyond their lipid-lowering effects. The aim of the present study was to delineate whether statin therapy has an impact on cancer risk and total mortality after heart transplantation. METHODS AND RESULTS: A total of 255 patients who underwent heart transplantation at the University Hospital Zurich between 1985 and 2007 and survived the first year were included in the present study. The primary outcome measure was the occurrence of any malignancy; the secondary end point was overall survival. During follow-up, a malignancy was diagnosed in 108 patients (42%). The cumulative incidence of tumors 8 years after transplantation was reduced in patients receiving a statin (34% versus 13%; 95% confidence interval, 0.25-0.43 versus 0.07-0.18; P<0.003). Statin use was associated with improved cancer-free and overall survival (both P<0.0001). A Cox regression model that analyzed the time to tumor formation with or without statin therapy, adjusted for age, male sex, type of cardiomyopathy, and immunosuppressive therapy (including switch to mTOR inhibitors or tacrolimus), demonstrated a superior survival in the statin group. Statins reduced the hazard of occurrence of any malignancy by 67% (hazard ratio, 0.33; 95% confidence interval, 0.21-0.51; P<0.0001). CONCLUSIONS: Although it is not possible to adjust for all potential confounders because of the very long follow-up period, this registry suggests that statin use is associated with improved cancer-free and overall survival after cardiac transplantation. These data will need to be confirmed in a prospective trial.

Transient global amnesia - not so rare after all.

QUESTION: Transient global amnesia (TGA) is characterised by the sudden occurrence of amnesia while lacking other neurological symptoms. Complete remission occurs within 24 hours. The pathogenesis remains unknown. The objective of this study was to evaluate the prevalence of TGA in a primary referral hospital in Uster, Switzerland and examine the accuracy of the diagnostic procedure and outcome. METHODS: We conducted a retrospective review of patients with TGA admitted to the Uster hospital, Switzerland between 1/2005 and 10/2007. Of 8166 patients, 20 consecutive cases fulfilled the diagnostic criteria and were further analysed. We included presenting symptoms, diagnostic tests performed, treatment and outcome. A questionnaire to investigate the treating doctor's knowledge of TGA was conducted. A follow up was conducted in all patients at 19.1 +/- 7.1 months after presentation. RESULTS: The incidence was 6.8/100 000/year. In all patients the symptoms resolved within 24 hours and all patients were seen by a consultant neurologist. Drug related causes were excluded. 25% episodes started after some form of exercise, 20% after emotional distress. All patients underwent cerebral imaging. 76% of the questionnaires sent to in-hospital physicians were returned. Diagnostic criteria of TGA were fully known in 75%. In 30% the diagnosis on admission was not TGA and had to be adjusted during the hospital stay. Follow up showed relapse in 10%. CONCLUSION: TGA is a syndrome of which emergency physicians should be aware. The diagnosis is made clinically and the prognosis is good, although relapses may occur. Missed diagnoses may lead to uncertainty in patients and their relatives.