The optimal blood pressure range for patients with coronary artery disease
(CAD) is not established, nor is it known whether patients with so-called
normal-range blood pressure might benefit from treatment with blood pressure–lowering
drugs. Nissen and colleaguesArticle report the results of a
randomized trial evaluating the effect of amlodipine or enalapril vs placebo
on cardiovascular events in normotensive patients with CAD. They found that
patients receiving amlodipine had significantly fewer cardiovascular events
than patients receiving placebo. For patients receiving enalapril, adverse
events were fewer but not statistically different compared with patients receiving
placebo. In a subgroup of patients undergoing intravascular ultrasound, patients
treated with amlodipine were found to have slowing of atheroma progression.
In an editorial, PepineArticle discusses the complexities of
determining optimal blood pressure for patients with CAD.
β-Blockers decrease cardiovascular risk in patients with hypertension
and type 2 diabetes mellitus (DM); however, they may worsen patients’
glycemic control. Bakris and colleagues report results of a randomized trial
of carvedilol vs metoprolol for patients with type 2 DM and hypertension receiving
renin-angiotensin system blockade, in which changes from baseline glycosylated
hemaglobin (HbA1c), insulin sensitivity, and microalbuminemia were
assessed. Following 5 months of maintenance therapy, the authors found patients
receiving carvedilol had significant improvements in HbA1c and
insulin sensitivity and less progression to microalbuminurea compared with
patients receiving metoprolol.
The metabolic syndrome is associated with cardiovascular disease, and
cardiovascular risk factors increase the risk of cognitive decline. However,
whether the metabolic syndrome is associated with cognitive decline is not
known. Yaffe and colleagues report results of an observational study of elderly
individuals that evaluated the association of the metabolic syndrome and high
levels of inflammatory markers with worsening cognition through 4 years of
follow-up. They found that participants with the metabolic syndrome had a
greater likelihood of cognitive decline compared with those without, and there
was a significant interaction of the metabolic syndrome and inflammation on
Dehydroepiandrosterone (DHEA), a widely available dietary supplement,
reduces abdominal fat and prevents insulin resistance in laboratory animals.
Villareal and Holloszy enrolled 56 elderly persons in a randomized placebo-controlled
trial to assess whether similar effects are seen in humans. They found significant
reductions in visceral and subcutaneous abdominal fat and an increase in insulin
sensitivity in the participants assigned to receive DHEA compared with those
assigned to receive placebo.
Stillbirth affects approximately 1 in 200 pregnancies. Identification
of women at high risk may allow effective intervention. Smith and colleagues
investigated whether maternal serum levels of 2 placental proteins—pregnancy-associated
plasma protein A (PAPP-A) and free β subunit of human chorionic gonadotropin
(HCG)—measured during the first 10 weeks of pregnancy could predict
the risk of antenatal stillbirth. They found that women with levels of PAPP-A
in the lowest fifth percentile had a significantly increased risk of stillbirth
due to placental dysfunction and that this risk was independent of maternal
characteristics. Maternal levels of free β subunit of HCG levels were
not related to stillbirth risk.
Success in preventing vision loss in mice with an inherited blinding
disorder and other recent studies are demonstrating the potential therapeutic
applications of stem cell research.
Slack discusses implications of patient e-mail access to clinicians
and Internet access to personal medical records for patient-physician communication,
patient care, and physician burden. In an editorial, Hersh discusses progress
in medical informatics and barriers to its broader adoption.
Empirical doxycycline therapy proved life-saving in a patient with human
monocytic ehrlichiosis, a disease with few specific clinical clues to diagnosis.
For your patients: Information about ehrlichiosis.
This Week in JAMA . JAMA. 2004;292(18):2189. doi:10.1001/jama.292.18.2189