Jan 20, 2017

Cross paths

The story

Your mother may or may not be a doctor, but she'll be the first to tell you that too much stress can make you sick. And while new research won't ask why you're not married yet or post photos of your awkward years on social media, it does back up Mom's claim that stress has ill effects on the heart.

The basics

Scientists have known for years that chronic stress increases the risk of heart disease almost as much as major risk factors like smoking, hypertension, and diabetes. But a mechanistic link joining stress and heart disease has never been proven. For one thing, it's hard to measure personal stress levels, and for another, it's hard to link those stress levels to atherosclerosis.

The link

Activation of the amygdala, a key part of the brain for emotion and stress, predicted risk of subsequent cardiovascular disease in an observational study of 300 patients who underwent FDG PET/CT cancer screening. After 4-year follow-up, high amygdalar activity, as measured by FDG uptake, was associated with increased rates of myocardial infarction, heart failure, and stroke.

The pathway

Since FDG imaging allows visualization of bone marrow activity and the activity of inflammatory cells in arteries, researchers were able to trace out a pathway linking stress in the amygdala to coronary artery plaque. Increased amygdala activation was associated with increased bone marrow activity (thought to represent the synthesis of inflammatory cells in response to stress) and increased arterial inflammation (inflammatory cells depositing plaque in arteries).

The takeaway

Many are calling this study the first physiological link between stress in the brain and heart disease, and point to stress reduction as a potentially critical tool in the worldwide fight against atherosclerosis. Since the study was observational, data proving causality is a logical next step.

Say it on rounds

When you do extra scut to avoid lazy third year status

It's tough to ditch labels once they stick. A Canadian study of 700 patients with physician-diagnosed adult-onset asthma found that a third of patients no longer had the disease. These patients were measured with serial methacholine inhalation challenges and were successfully weaned off controller medications. Since half of the study population did not have spirometry or peak flow testing at the time of diagnosis, make sure to send your asthma patients for PFTs if their diagnosis has never been proven.

When you avoid mirrors at the end of 24-hour call

Trust us, you're no worse for wear. After all, 18 people in Brooklyn this summer were dubbed zombies after they were brought to an emergency department following a party, and they recovered just fine. The culprit? AMB-FUBINACA, a synthetic cannabinoid that carries the street name "AK-47 Karat Gold." Intoxicated patients presented with blank stares, groans, and slow mechanical movements of the arms (see this cartoon video to get a better idea). The drug evaded standard urine toxicology, and most patients had normal vital signs and reflexes. The 'zombie outbreak' is part of a larger rise in the use of synthetic marijuana, which is cheap and difficult to detect.

When you can't choose between the Packers and the Falcons

Anything but the Patriots is fine with us, but it's tough to make the right choice when you have good options that seem similar. A retrospective, population-based study of GI bleeding in patients with atrial fibrillation on novel oral anticoagulants (NOACs) found that apixaban had the most favorable safety profile while rivaroxaban had the least. For all NOACs, GI bleeds increased with age, and those aged 75 years or more faced the highest risk. 

Brush up

Hypertension guidelines

Expert recommendations on blood pressure (BP) targets in the elderly have recently been in flux. 2014's JNC 8 guidelines recommended a BP target of < 150/90 mmHg for patients 60 and older, but 2015's SPRINT trial was stopped early after it found evidence that a systolic blood pressure (SBP) target of < 120 mmHg reduced mortality in high cardiovascular (CV) risk patients. In response, the ACP and AAFP published joint guidelines this week for blood pressure control in patients over age 60. They recommend an SBP target < 150 mmHg for low CV risk patients, and an SBP target < 140 mmHg for high CV risk patients. 

Get meta

With blood pressure targets in patients aged 60 years or older. An analysis of 21 blood pressure trials published concurrently with the new joint ACP/AAFP guidelines found high-strength evidence that a BP target of < 150/90 mmHg reduces mortality in elderly patients. While the evidence base for lower targets, including the SBP < 120 mmHg target used in SPRINT, was less robust, there was no evidence that lower targets increased falls or cognitive impairment.

What your health policy friends are talking about

Jimmy Kimmel wants you to know that some Americans still don't realize that ObamaCare and the Affordable Care Act are the same thing. If it all sounds familiar, a similar video was made in 2013.

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