Journals Watch - TIA, CVD risk and influenza

Have you been too busy to read the journals? Dr Louise Newson brings you the latest research.

Narrowed carotid artery: TIA is a medical emergency and patients should present immediately to hospital
Narrowed carotid artery: TIA is a medical emergency and patients should present immediately to hospital

Patients with TIAs are still not going to emergency departments Emerg Med J 2010; 27: 364-7
There have been many adverts highlighting FAST (face-arms-speech-time) to encourage patients and healthcare professionals to manage TIAs as medical emergencies. However, many patients in the UK are still presenting later after having a TIA.

This study looked at whether patients with a TIA were more likely to present to their GP rather than an emergency department. They discovered that more than half of patients did not present to a doctor on the same day of their TIA.

Most UK patients went to their GP, whereas the majority of Canadian patients attended the emergency department. There was a delay in UK patients who presented with a TIA over the weekend.

This study highlights the need for improved education in the UK so a TIA is perceived as a medical emergency and patients promptly attend their local emergency departments.

NSAID use in healthy people linked to increased cardiovascular disease risk Circ Cardiovasc Qual Outcomes 2010; 303: 2156-64
Over the past few years, I have become more cautious when prescribing NSAIDs to patients with a history of cardiovascular disease (CVD). This research from Denmark has illustrated that perhaps I am not being cautious enough.

The authors showed that the use of certain NSAIDs is actually associated with an increase CVD risk, even in healthy people.

Diclofenac was shown to be associated with the highest cardiovascular risk, and the use of ibuprofen was associated with a 1.29-fold increased risk for fatal or non-fatal stroke.

It appears that naproxen was the safest NSAID as its use was not associated with increased risk for CVD death, although it was associated with a trend towards increased risk for non-fatal or fatal stroke risk.

The risk increased with higher doses.

Perhaps low-dose naproxen is now the most preferable NSAID for patients.

Sugar-sweetened drinks and BP Circulation 2010; 121: 2398-406
It is well known that a poor diet can adversely affect BP control. Studies using animal models have shown that increased sugar intake can induce hypertension, even after controlling for weight.

Sugar-sweetened drinks are defined as any with added sucrose or high-fructose corn syrup, including soft drinks, fruit drinks, lemonade and other sweetened drinks, but excluding diet drinks.

This study involved more than 800 adults and found that drinking one less sugar-sweetened drink a day was associated with a reduction in BP of about 1.2mmHg and 1.1mmHg in systolic and diastolic BP, respectively, over 18 months. This was independent of any weight reduction.

So perhaps we should be asking our patients about their consumption of soft drinks in addition to asking about their diet.

Oseltamivir ring prophylaxis for containment of 2009 H1N1 influenza outbreaks N Engl J Med 2010; 362: 2166-74

There seemed to be confusion regarding the advantages of giving prophylactic tamiflu (oseltamivir) to reduce the transmission of influenza. This study looked at the efficacy of giving ring prophylaxis with oseltamivir. This is geographically targeted containment by giving prophylaxis in order to control outbreaks of 2009 H1N1 influenza in semi-closed environments.

This study was based in Singapore military camps. All those with suspected infection were tested and those who tested positive were clinically isolated.

Post-exposure ring prophylaxis was given with oseltamivir and the affected military units were segregated. They were then screened for the virus three times a week.

These results confirmed that this was an effective method of reducing the rate of infection.

Infection occurred in 6.4 per cent of people before the intervention compared with only 0.6 per cent after the intervention.

This shows that with prompt identification and isolation of infected people, this method is effective at reducing the impact of outbreaks of H1N1 influenza.

Managing hypertension in chronic kidney disease Br J Gen Pract 2010; 60 (575), 258-e265
People with chronic kidney disease (CKD) have a higher risk of suffering from cardiovascular events and therefore controlling systolic BP is important in slowing disease progression as well as reducing cardiovascular mortality and morbidity.

This systematic review was conducted to assess the effectiveness of quality-improvement interventions to lower BP in people with CKD.

These interventions were grouped into educational interventions, interventions providing audit and comparative feedback and organisational or team change.

The studies selected for review mainly included participants from high-risk populations. Analysis found three randomised trials which showed a combined effect of a reduction in systolic BP of 10.5mmHg and one non-randomised study showed a reduction in systolic BP of 9.3mmHg.

The researchers conclude that quality-improvement interventions can be effective in lowering BP and potentially in reducing cardiovascular risk in high-risk patients. Trials are now needed in lower risk patients to see if the same interventions are beneficial.

The Quick Study

TIA education needs to be improved in the UK so it is perceived by patients as a medical emergency.

Cardiovascular disease was shown to increase with NSAID use, even in healthy people.

BP can be lowered by reducing consumption of sugar-sweetened drinks.

H1N1 infection can be effectively reduced by giving ring prophylaxis using oseltamivir.

CKD patients were shown to benefit from quality-improvement interventions to lower BP, and potentially cardiovascular risk.

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

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