Although cigarette smoking is a major risk factor for acute myocardial infarction (MI), cigarette tar yield has not been clearly demonstrated to affect MI risk. A case-control study was performed to measure the association between cigarette yield and MI. The authors conclude that smoking higher-yield cigarettes is associated with an increased risk of MI, and there is a dose-response relationship between total tar consumption per day and MI. They also emphasize that prior studies have demonstrated that smoking cessation remains the only proven method for reversing the increased risk of MI among smokers.
Although commonly prescribed for acute bronchitis, exacerbations of asthma and chronic bronchitis, acute pharyngitis, and acute sinusitis, antibiotics rarely benefit patients with these disorders and frequently produce numerous adverse effects. Rather than prescribe antimicrobial therapy, clinicians should provide symptomatic treatment and delineate the expected course of these self-limited diseases. Most patients, even those expecting antibiotics, accept this approach if they feel that the practitioner has reassured them that their problem is not serious, has demonstrated a personal interest in them, and has explained their diagnosis.
Nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with a first hospitalization of congestive heart failure (CHF). Based on the pathophysiology of NSAID-induced CHF, however, it seems more likely that NSAIDs may precipitate relapsing CHF in patients with prevalent heart failure and that NSAIDs are less likely to induce a first occurrence of heart failure. Therefore, Feenstra and colleagues estimated the risk of NSAID-induced CHF in patients with incident CHF as well as in patients with prevalent CHF in a prospective population-based cohort study. Current use of NSAIDs was associated with a relative risk of incident CHF of 1.1 (95% confidence interval [CI], 0.7-1.7) after adjustment for age, sex, and concomitant medication. In patients with prevalent heart failure who filled at least 1 NSAID prescription since being diagnosed as having CHF, the univariate and adjusted relative risks of a relapse of CHF were, respectively, 3.8 (95% CI, 1.1-12.7) and 9.9 (95% CI, 1.7-57.0). The authors conclude that NSAIDs are not associated with an increased risk of incident CHF. In patients with prevalent CHF, current use of NSAIDs is associated with a substantially increased risk of relapsing CHF.
Dilutional hyponatremia in patients with cirrhosis is accepted as an intermediate event in the sequence that leads to hepatorenal syndrome. However, clinical or analytical data that could predict the development of hyponatremia and the course of patients with cirrhosis and hyponatremia have received very little attention. Porcel et al found a higher percentage of patients with hyponatremia had decreased liver size and higher levels of plasma renin activity and serum concentrations of aldosterone and noradrenaline. In half of these patients, hyponatremia followed a complication (gastrointestinal tract bleeding or bacterial infection) that could have precipitated activation of vasoactive systems. Natremia levels returned to the reference range in the patients surviving those precipitating events. Hyponatremia persisted in the patients in whom it developed spontaneously in the absence of precipitating factors. The median survival after the diagnosis of spontaneous hyponatremia was 111 days. Most (85.2%) of these patients died from hepatorenal syndrome. Multivariate analysis showed that Child-Pugh index, presence of hepatocellular carcinoma, and serum levels of urea were associated with mortality. However, a reduced sodium concentration could not be considered as a independent predictor of the risk of death.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2002;162(3):243. doi:10.1001/archinte.162.3.243