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Nov 17, 2017

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The story

In medicine, even a casual suggestion – think: 'maybe you should do a rectal, just to be thorough' – is really more of a command. So what's to make of new guidelines encouraging lower blood pressure?

The background

The SPRINT trial shocked experts in 2015 when it found that aggressive blood pressure targets reduced heart attacks in patients with known cardiac risk factors. The meds involved were cheap, and the effect size – a 27% decrease in all-cause mortality for those who targeted a systolic blood pressure (SBP) < 120 mm Hg – stretched far beyond expectations. Prior guidelines that encouraged a target of < 140/90 mm Hg seemed immediately out of date. 

The targets

The AHA and ACC dropped a much-awaited successor to 2003's JNC 7 this week to accompanying headlines like "28 million Americans were just diagnosed with high blood pressure". The basic gist is that prehypertension, previously defined as SBP between 120 and 139 mm Hg, is gone, and the threshold for a hypertension diagnosis has fallen by 10 mm Hg. Take a look:
  • Normal: Less than 120/80 mm Hg
  • Elevated: Systolic between 120-129 and diastolic less than 80
  • Stage 1: Systolic between 130-139 or diastolic between 80-89
  • Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg
The new guidelines ask providers to recognize white-coat hypertension and to use at-home or ambulatory blood pressure monitoring when feasible.
Hypertension

The meds

While a lot more people will now be called hypertensive, only a fraction of the newly diagnosed will need treatment. In keeping with SPRINT, Stage 1 hypertensives should be treated with medication only if they have cardiac risk factors, specifically an ASCVD 10-year risk of > 10%. The great majority of these patients needed treatment anyway, only now they are encouraged to use more medications to reach a lower BP goal.

The takeaway

By calling more people hypertensive, the new guidelines aim to raise awareness and promote diet and exercise. In functional terms, they lower blood pressure targets for patients with cardiac risk factors already on treatment.

Say it on rounds

When you're late to the holiday party and need to catch up

Get after it. Early clot removal improves outcomes in ischemic stroke, but many patients present outside of the established 6-hour time window. The DAWN trial looked at endovascular thrombectomy in 200 patients who presented with stroke between 6 and 24 hours after the onset of symptoms. The trial used imaging to identify candidates with ischemic but not yet infarcted brain tissue, and was stopped early after the thrombectomy group had over three times the rate of functional independence at 90 days compared to standard-of-care.
NEJM

When coffee helps you stay awake and stay regular

Two birds, one stone. A meta-analysis of intrauterine device (IUD) use and incident cervical cancer found that the contraceptive lowered the risk of cervical cancer by 30%. The IUD's proximity to the cervical transformation zone is thought to play a protective role. Since the studies were done before the HPV vaccine was available, whether the benefit applies to young women who've been vaccinated remains unclear.
Obstet Gynecol

When you imagine a future of macadamia cookies and pecan pie

You've always been more of a long-term thinker. A 30-year look at nut consumption across three large population health studies basically found the more the better. About one ounce of nuts a week reduced the risk of heart disease by 10% after controlling for other coronary risk factors, and the benefits almost doubled at 5 servings a week. Even peanuts were associated with risk reduction. 
JACC

Brush up

Bacterial meningitis

The incidence of bacterial meningitis has fallen due to the widespread use of conjugate vaccines. But be suspicious: in adults, mortality can still be as high as 30%. More than 95% of patients will present with any two of the following: headache, fever, neck stiffness, and altered consciousness. Lumbar puncture is essential for diagnosis, while the backbone of therapy is a third-generation cephalosporin (often ceftriaxone) along with vancomycin in areas where resistance is high. Add ampicillin in patients over age 60 to cover Listeria.

What's the evidence

For steroids in bacterial meningitis? A 2002 European RCT of 300 patients found that administration of 10 mg of dexamethasone reduced death and unfavorable outcomes like hearing loss compared to placebo. Benefits were most striking in pneumococcal meningitis. While subsequent studies and analyses have prompted debate on whether dexamethasone improves outcomes, it's generally agreed that steroids do not have major adverse effects and add value in pneumococcal disease.

What your tech friends are talking about

If you thought your pager would go digital before the medicines that you dispense, then guess again. In an effort to stamp out non-compliance, the FDA approved a digital pill (the antipsychtoic aripiprazole or Abilify) that sends an electrical signal to a patch worn on the patient's chest after it encounters stomach acid. The info ultimately finds its way to a smartphone app.

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We're off next week for Thanksgiving. We hope the call schedule left you off work, but if it didn't, we hope there are plenty of leftovers in the resident lounge.

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