CVD risk, gout and HRT patches

Too busy to catch up on the latest research? Let Dr Louise Newson update you on recent papers.

Exercise ECGs in diabetic men Circulation 2008; 117: 2,734-42

Exercise ECGs are often used to investigate chest pain and angina, although obviously angiograms are the gold standard investigation.

This study examined the association between exercise ECG response and mortality in 2,854 diabetic men with no prior history of cardiovascular disease (CVD) over an impressive 27-year period.

Mortality due to all causes, CHD and CVD were the main outcome measures.

Even after adjusting for other cardiovascular risk factors, such as smoking or hypertension, equivocal and abnormal exercise ECG responses were associated with higher risk of mortality - both from CVD and all cause.

I wonder whether this means that these patients should have their cardiovascular risk factors more aggressively managed than those with normal exercise ECGs.

Depression in stroke patients JAMA 2008; 299: 2,391-400
Depression occurs in over half of patients following a stroke. As many cases of depression in stroke patients are often diagnosed late or not diagnosed at all, prevention of depression seems very attractive.

In this trial, 176 patients (who were not depressed) were given the antidepressant escitalopram over the first year following their stroke to determine whether treatment after acute stroke would decrease the number of depression cases that develop compared with placebo medication.

Although the numbers were small, the results showed that patients who received placebo were significantly more likely to develop depression compared with those who had received escitalopram.

I do not think we should recommend treating all patients with antidepressants following their stroke, but this study does serve as a reminder of the importance of diagnosing and treating depression in patients who have recently had a stroke.

Gout - another risk factor for cardiovascular disease? Arch Intern Med 2008; 168: 1,104-10
We are aware of many diseases that are associated with a higher risk of CVD, including hypertension, diabetes and even rheumatoid arthritis and SLE. Studies have also shown that gout is associated with CVD, including MI.

This US study showed that gout is associated with increased CVD mortality in middle-aged men, especially those with gout accompanied by hyperuricaemia. Those with gout had higher unadjusted mortality rates from CVD than those without gout, at 10.3 versus 8.0 per 1,000 person-years; this equates to an approximately 30 per cent increased relative risk.

HRT patches and the risk of thromboembolism BMJ 2008; 336: 1,227-31
Many studies have shown that there is an increased risk of venous thromboembolism with oral HRT.

This review and meta-analysis has found similar results: the risk of venous thromboembolism doubled with oral HRT compared with placebo.

This increased risk was higher within the first year of treatment and in those with other risk factors for thromboembolism, for example, obese women.

However, this increased risk was not seen for those women who were receiving transdermal oestrogen, interestingly even in those with other risk factors for thromboembolism.

As pulmonary embolism is a insignificant potentially fatal event associated with HRT, perhaps transdermal HRT should be offered to women, especially those with risk factors for clots, instead of prescribing oral HRT?

Topical steroids to treat sunburnt skin Arch Dermatol 2008; 144: 620-4

Although the majority of people are aware of the harmful effects of the sun, it is not uncommon to see patients with acute sunburn in our surgeries after a particularly sunny weekend.

This randomised, double-blind trial examined the effect of topical corticosteroid treatment on acute sunburn, in 20 healthy volunteers with a variety of skin types.

Using the sunburn improvement factor as the main outcome measure, the results showed that treating sunburnt skin with either moderate- or high-potency corticosteroids did not lead to a reduction in the acute sunburn reaction when used either six or 23 hours after exposure to the sun. Results were the same for skin that burns easily and for skin that tans easily.

The solution is surely to not get sunburnt in the first instance.

Osteoporosis medication in nursing homes Arch Intern Med 2008; 168: 1,111-5
Over the past few years we have become more aware of the importance of treating osteoporosis, especially for those patients at high risk of fracture.

This US study looked at the rates of treatment for osteoporosis in elderly patients in a 12-month period after being admitted to a nursing home since sustaining a fracture to the hip, wrist or humerus.

The results were worse than expected - out of the 4,430 patients who should have been receiving treatment, only 11.5 per cent were prescribed osteoporosis medication.

Patients with a previous history of falls were more likely to have received treatment. The rate of osteoporosis medication use actually increased across the 10-year period.

Hopefully, the results of a similar study from the UK would show better results.

Dr Newson is a GP in the West Midlands and a member of our team who regularly review the journals.

The quick study

  • Abnormal exercise ECG responses were associated with a higher risk of mortality in diabetic men.
  • Stroke patients were less likely to become depressed if given prophylactic antidepressants.
  • Gout accompanied by hyperuricaemia is associated with increased CVD mortality in middle-aged men.
  • Transdermal oestrogen does not increase the risk of venous thromboembolism even in women with other risk factors.
  • Topical corticosteroids do not lead to a reduction in acute sunburn reaction.
  • Osteoporosis medication is not prescribed in US nursing homes at an appropriate rate for patients at high risk of fracture.

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