Faculty Bibliography

PURPOSE: Patients with type 2 diabetes are commonly overweight, which can contribute to poor cardiovascular outcomes. beta-blockers may promote weight gain, or hamper weight loss, and are a concern in high-risk patients. The current analysis of the Glycemic Effect in Diabetes Mellitus: Carvedilol-Metoprolol Comparison in Hypertensives (GEMINI) trial evaluates the effects of carvedilol and metoprolol tartrate on weight gain in patients with type 2 diabetes and hypertension. METHODS: This prespecified secondary analysis of the GEMINI study (n=1106) evaluated change in body weight after 5 months. RESULTS: Mean (+/-SE) baseline weights were 97.5 (+/-20.1) kg for carvedilol and 96.6 (+/-20.1) kg for metoprolol tartrate. Treatment difference (c vs m) in mean (+/-SE) weight change from baseline was -1.02 (+/-0.21) kg (95% confidence interval [CI], -1.43 to -0.60; P <.001). Patients taking metoprolol had a significant mean (+/-SE) weight gain of 1.19 (+/-0.16) kg (P <.001); patients taking carvedilol did not (0.17 [+/-0.19] kg; P =.36). Metoprolol tartrate-treated patients with body mass index (BMI) >30 kg/m2 had a statistically significant greater weight gain than comparable carvedilol-treated patients. Treatment differences (c vs m) in the obese (BMI >30 kg/m2) and morbidly obese groups (BMI >40 kg/m2) were -0.90 kg (95% CI, -1.5 to -0.3; P =.002) and -1.84 kg (95% CI, -2.9 to -0.8; P =.001), respectively. Pairwise correlation analyses revealed no significant associations between weight change and change in HbA1c, HOMA-IR, or blood pressure. CONCLUSIONS: Metoprolol tartrate was associated with increased weight gain compared to carvedilol; weight gain was most pronounced in subjects with hypertension and diabetes who were not taking insulin therapy

About 65 million Americans, one fourth of the adult population in the United States, and over 1 billion people worldwide have hypertension (HTN). HTN therefore is present in 1 of every 4 patients admitted to any US hospital. Surprisingly, no guidelines are available for the management of inpatient HTN. Based on a comprehensive search of the literature we are proposing a pathway for the management of HTN in nonpregnant hospitalized patients. The pathway provides a definition and clinical assessment of HTN for patients admitted to the hospital. The assessment is followed by an organ/system based therapeutic approach specifying timing, blood pressure goals, recommended antihypertensive drug therapy and the sequence of add-on drugs. The pathway specifically discusses assessment and management of HTN in patients with (1) acute aortic syndrome, (2) acute neurologic syndrome, (3) acute coronary syndrome, (4) congestive heart failure, (5) renal failure, and (6) secondary forms. Finally, the pathway provides a step by step recommendation for the management of in hospital HTN and of hypertensive emergencies

OBJECTIVES: The purpose of this study was to evaluate the prognostic value of assessing right ventricular (RV) wall motion abnormalities during stress echocardiography (SE). BACKGROUND: The results of SE are usually interpreted based on wall motion abnormalities of the left ventricle (LV). There is increasing recognition of the prognostic importance of RV. However, RV is still a 'forgotten' chamber during routine SE. METHODS: We evaluated 2,703 patients referred for SE. The LV was evaluated on a 16-segment model 5-point scale and the RV was evaluated on a 3-segment model 5-point scale for wall motion abnormalities. An abnormal RV or LV was defined as one with new (ischemic) or fixed (infarction) wall motion abnormalities. Follow-up (2.7 +/- 1.0 years) for confirmed myocardial infarction and cardiac death (n = 122) were obtained. RESULTS: An abnormal RV was seen in 112 patients (4%). In the presence of an abnormal LV, patients with abnormal RV had a worse prognosis than those with normal RV. Abnormal RV was a significant predictor of events (adjusted hazard ratio 2.69, 95% confidence interval 1.22 to 5.92; p = 0.014) independent of LV ischemia and ejection fraction. A forward conditional Cox model showed that peak RV wall motion score index provided incremental prognostic value over rest and conventional SE variables (global chi-square increased from 141.4 to 161.8 to 197.0; p < 0.0001 and p = 0.006, respectively). CONCLUSIONS: In patients referred for SE, RV wall motion analysis provides prognostic value independent of LV ischemia and ejection fraction and provides incremental value over rest and conventional SE variables. Right ventricular wall motion analysis should be routinely performed in patients referred for SE for effective risk stratification

Traditionally, beta-blockers, used as first-line agents to treat uncomplicated hypertension, were recommended by national and international guidelines despite a paucity of evidence regarding their cardiovascular benefit. However, evidence from recent trials and meta-analyses has questioned the use of beta-blockers as preferred agents. This article reviews the data available from clinical trials and argues that beta-blockers are less efficacious than other currently available antihypertensive agents for patients with uncomplicated hypertension