Faculty Bibliography

BACKGROUND: While strong associations are seen between serum uric acid levels and gout and cardiovascular disease (CVD), few studies have assessed differences between gout patients (pts) with and without CVD.
OBJECTIVE(S): To compare disease and comorbidity characteristics among gout pts with and without CVD, identifying differences in treatment patterns and healthcare utilization in a real-world cohort.
METHOD(S): Data were assessed from a survey of U.S. physicians and in-depth patient chart audits. Severity of gout was measured by physician global assessment, flares, organ/joint damage, and tophi. Type/dose of xanthine oxidase inhibitor, length of current treatment, sociodemographic factors, and physician type were identified. Multivariate and descriptive statistics described differences among pts with and without CVD and assessed urate-lowering therapy (ULT) use and gout disease control.
RESULT(S): 1159 patient charts were abstracted (738, CVD; 421, no CVD; 81% male; 38% >= 61 y; 71% white). Pts with CVD had longer duration of gout (52 vs. 34 mo; P < 0.001) and were more likely to have clinician-reported tophi (28% vs. 15%; P < 0.001), organ/joint damage (19% vs. 9%; P < 0.001), severe gout (19% vs. 11%; P < 0.001), and more flares in the past 12 mo. (2.1% vs. 1.8%; P = 0.017). Time from gout diagnosis to start of ULT was delayed for those with CVD (24 vs. 16 mo.; P = 0.02), but these pts were more likely to be on ULT (83% vs. 59%; P < 0.001). Gout pts with CVD were more likely to have obesity (28% vs. 18%; P < 0.001), diabetes (26% vs. 12%; P < 0.001), osteoarthritis (25% vs. 11%; P < 0.001), chronic kidney disease (17% vs. 5%; P < 0.001), and prostate disease (males, n = 933; 10% vs. 2%; P < 0.001). Gout pts with CVD were more likely to have an emergency department visit for gout in the past 12 mo. (12% vs. 7%; P = 0.003). Overall, ULT use was associated with better gout control. In a backward, stepwise logistic model in pts with CVD, those more likely be treated with ULT had organ/joint damage (odds ratio [OR] = 13.3), severe gout (OR = 1.5), or prostate disease (OR = 4.2), but these were not significant predictors for pts without CVD.
CONCLUSION(S): In this study, pts treated with ULT were more likely to have better gout control. Gout pts with CVD were more likely to be on ULT, despite delayed initiation of therapy. Given that gout pts with CVD were more likely to have additional comorbidities and more severe gout, the delay in treatment may be associated with the severity of disease in these pts. These data suggest that gout pts with CVD constitute a less healthy group in need of earlier, more aggressive therapy

Objective: The optimal blood pressure(BP) target has been a matter of debate. The recent SPRINT trial showed significant benefits of a BP target of <120 mmHg albeit with an increase in serious adverse effects (SAE). Design and method: PUBMED/EMBASE/CENTRAL were searched for randomized trials comparing treating to different BP targets. Trial arms were grouped into five systolic BP target categories: 1) < 160 mmHg; 2) < 150 mmHg; 3) < 140 mmHg; 4) < 130 mmHg and 5) < 120 mmHg. Efficacy outcomes of stroke, myocardial infarction, death, cardiovascular death, heart failure and safety outcomes of SAE were evaluated using a network meta-analysis. Results: Seventeen trials that enrolled 55,163 patients with 204,103 patient-years of follow-up were included. There was a significant decrease in stroke (RR = 0.54; 95% CI 0.29-1.00) and myocardial infarction with systolic BP < 120 mmHg (vs. < 160 mmHg) (RR = 0.68; 95% CI 0.47-1.00). Sensitivity analysis using achieved systolic BP showed a 72%, 97% and 227% increase in stroke with systolic BP of < 140 mmHg, < 150 mmHg and < 160 mm when compared with systolic BP < 120 mmHg. There was no difference in death, cardiovascular death or heart failure when comparing any of the BP targets. However, the point estimate favored lower BP targets (< 120 mmHg, < 130 mmHg) when compared with higher BP targets (< 140 mmHg or <150 mmHg). BP targets of < 120 mmHg and < 130 mmHg ranked #1 and #2 as the most efficacious target. There was a signifi- cant increase in SAE with systolic BP <120 mmHg vs. <150 mmHg (RR = 1.83; 95% CI 1.05-3.20) or vs. <140 mmHg (RR = 2.12; 95% CI 1.46-3.08). BP targets of < 140 mmHg and < 150 mmHg ranked #1 and #2 as the safest target for the outcome of SAE. Cluster plots for combined efficacy and safety showed that a systolic BP target of < 130 mmHg had optimal balance between efficacy and safety. Conclusions: Among patients with cardiovascular disease, a systolic BP target of < 130 mmHg achieved optimal balance between efficacy and safety

Hydrochlorthiazide (HCTZ) is one of the most commonly prescribed antihypertensive drugs worldwide. More than 97% of all HCTZ prescriptions are for 12.5 to 25 mg per day. The purpose of this study was to evaluate the antihypertensive efficacy ofHCTZby clinic blood pressure (BP) and ambulatory BP (ABP) monitoring when compared to other anti-hypertensives. A systematic review was performed using Medline, Cochrane, Scopus and Embase databases for all randomized trials that assessed both clinic and 24-h ABP with HCTZ in comparison with other antihypertensive drugs. In addition, trials were selected only if they studiedHCTZas monotherapy and have trial duration of at least 4 weeks. Eleven studies (16 comparisons) with 918 patients fulfilled the inclusion criteria. All the studies used HCTZ dose 12.5 to 25 mg/day except one study that used a dose of 25-50 mg/day. The decrease in clinic BP with HCTZ was systolic 12.1mmHg (95% confidence interval [CI]: 6.0 to 18.3mmHg) and diastolic 6.3mmHg (95% CI: 2.8 to 9.9 mm Hg). The reduction in 24-h ABP with HCTZ was systolic 6.4 mm Hg (95% CI: 5.0 to 7.7 mm Hg) and diastolic 3.3 mm Hg (95% CI: 1.8 to 4.9 mm Hg). In head-to-head comparisons with other antihypertensive drug classes, compared to HCTZ, ACE inhibitors/ARBs resulted in significant greater reduction in systolic clinic andABPby 4.5/2.3mmHg, beta-blockers by 8.1/6.2 mm Hg, calcium antagonists by 3.2/2.5 mm Hg and thiazide-type diuretics by 7.8/5.3 mm Hg. Similarly, other anti-hypertensive drug classes resulted in significantly greater reduction of diastolic ABP and clinic

Background: In the United States, 40% of African Americans are disproportionately affected by hypertension leading to severe comorbidity and eventual mortality. Ethnic differences in hypertension among the various African American groups are not well documented. We evaluated the blood pressure control rates of Caribbean and West African born African Americans compared to US born African Americans attending New York City Health and Hospitals Corporation (NYC HHC) facilities. Methods: Data from NYC HHC clinical data warehouse were extracted for hypertensive patients seen between January 2004 and December 2009. Ethnic origin was based on self-reported country of birth (United States, the Caribbean, and West Africa). Blood pressure (BP) was scored by taking the average of 3 or more blood pressure measurements over the course of 3 months of HHC data. All BP measurements were made in the clinical setting and uncontrolled hypertension was defined as BP >140/90 mm Hg. All BPs were measured at least 4 months after hypertension diagnosis. We also extracted information regarding comorbid diagnoses, number of prescribed antihypertensive classes, number of medical visits, age, sex, BMI and mortality. We compared the groups using cox proportional hazard regression models. Results: The sample was composed of 25,142 African Americans of whom 13,778 (54.8%) were US born, 10,032 (39.9%) were Caribbean born, and 1,332 (5.3%) were West African born. The mean sample age was 51 (14.2) years, the mean BMI was 32.4 (11.0) and the sample was 61.4% (N=15,449) female. Compared to US born African Americans, Caribbean and West African born African Americans had higher levels of systolic blood pressure (3.8mmHg; p<.001 and 2.4mmHg; p<.001 respectively) and were more likely to have uncontrolled BP (OR=1.40;p<.001 and OR=1.21;p=.002, respectively). These differences were found in unadjusted models and after adjustment for age, sex, BMI, number of classes of antihypertensive medications prescribed, comorbidity, number of BP measurements, and length of HTN diagnosis. However, US born African Americans had higher rates of mortality (11.6%) compared to Caribbean born (6.0%) and West African born (2.5%) African Americans, which was confirmed by unadjusted and fully adjusted cox proportional hazards regression models. Conclusion: Ethnic differences in cardiovascular outcomes and mortality exist among hypertensive African Americans served by NYC HHC. US born African Americans have a lower survival rate despite lower BP and better BP control than Caribbean and West African born African Americans. Future studies on African Americans should take ethnic variations within these populations into account

BACKGROUND: The benefit of </=6-month compared with 12-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) placement remains controversial. We performed a meta-analysis and meta-regression of 40 was identified, effects were obtained with random models. RESULTS: Nine RCTs were included with total n = 19,224 patients. No significant differences were observed between