How Should We Advise Heart Failure Patients on Exercise and What Should We Tell Them?

The article discusses the problem of motivating and encouraging patients with heart failure to perform regular exercise training. Firstly, the benefits of exercise training are presented, and rational and convincing arguments justifying its implementation in heart failure patients are provided. Secondly, the issue of overcoming barriers to exercise training implementation is considered. Finally, the role of the medical team and family members in supporting patients with heart failure in long-term adherence to recommendations is defined and analyzed. In addition, the article presents various ways of performing exercise training easily.     

Mixed Incontinence: How Best to Manage It?

Although common in women, mixed urinary incontinence (MUI) is under-reported and under-treated. It is linked to concomitant disturbances, which may be due to childbirth, ageing, or other medical conditions, in the complex bladder-urethra coordinated system of urine storage and emptying. Primary care physicians can evaluate MUI through history and simple clinical assessment or they can avail of more complex device and tools, such as urodynamic assessment. There is a wide range of therapeutic options. The recent proliferation of new drug treatments and surgical devices for urinary incontinence offers innovative strategies for therapy but products risk being introduced without long-term safety and efficacy assessment. Direct-to-consumer advertising has increased public awareness of MUI.     

The Metabolic Syndrome—What Is It and How Should It Be Managed?

Following a hypertension symposium in Portland, ME, in October 2005, a roundtable was convened to discuss the metabolic syndrome and its significance. Dr. Marvin Moser of the Yale University School of Medicine, New Haven, CT, moderated the discussion. Participating in the discussion were Dr. Bonita Falkner of the Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Dr. Michael A.Weber of SUNY Downstate College of Medicine, New York, NY; and Dr. Leonard Mark Keilson of the University of Vermont College of Medicine.     

What Should We Tell Patients with Heart Failure about Sodium Restriction and How Should We Counsel Them?

This article is a review of current evidence regarding the recommended level of dietary sodium, involvement of family members in adoption of a low sodium diet, and evidence-based strategies to increase patient and family member willingness and ability to a follow a low sodium diet. The available evidence suggests that recommending a 2.5 to 3 g sodium diet will meet nutritional needs and decrease risk of hospitalizations. The best strategy identified for patient success is to fully involve both patients and family members in jointly reducing sodium intake. Motivational interviewing techniques should be used before counseling begins to guide patients and family members toward realization of the need to follow a low sodium diet. Successful counseling starts with determining perceptions, barriers, and individual characteristics that impede adherence. This information is incorporated into theory-based teaching strategies to promote behavior change and successful adoption of a low sodium diet.     

What is the Role of Aldosterone Excess in Resistant Hypertension and How Should It Be Investigated and Treated?

Resistant hypertension has evolved as an important global health care problem. Primary aldosteronism is one of several potentially reversible causes of resistant hypertension. Primary aldosteronism can be effectively treated, when recognized, with a mineralocorticoid receptor antagonist, such as spironolactone and eplerenone. Each of these compounds can reduce blood pressure as monotherapy or when given with a range of other antihypertensive drug classes. These compounds have distinctive pharmacokinetic and pharmacodynamic patterns that require some forethought in their use before they are prescribed. However, as the use of mineralocorticoid-blocking agents has gradually increased, the hazards inherent to use of such drugs has become more apparent. Whereas the endocrine side effects of spironolactone are in most cases little more than a cosmetic annoyance, the potassium-sparing effects of both spironolactone and eplerenone can prove fatal if sufficient degrees of hyperkalemia develop. However, for most patients the risk of developing hyperkalemia in and of itself should not discourage the prudent clinician from bringing these compounds into play. Hyperkalemia should always be considered as a likelihood in any patient receiving one or the other of these medications. As such, steps should be taken to lessen the likelihood of it occurring if therapy is being contemplated with agents in this class.     

Microalbuminuria: What Is It? Why Is It Important? What Should Be Done About It? An Update

Microalbuminuria (MA) is defined as a persistent elevation of albumin in the urine of >30 to <300 mg/d (>20 to <200 microg/min). Use of the morning spot urine test for albumin-to-creatinine measurement (mg/g) is recommended as the preferred screening strategy for all patients with diabetes and with the metabolic syndrome and hypertension. MA should be assessed annually in all patients and every 6 months within the first year of treatment to monitor the impact of antihypertensive therapy. It is an established risk marker for the presence of cardiovascular disease and predicts progression of nephropathy when it increases to frank microalbuminuria>300 mg/d. Data support the concept that the presence of MA is the kidney's warning that there is a problem with the vasculature. The presence of MA is a marker of endothelial dysfunction and a predictor of increased cardiovascular risk. MA can be reduced, and progression to overt proteinuria prevented, by aggressive blood pressure reduction, especially with a regimen based on medications that block the renin-angiotensin-aldosterone system, and control of diabetes. The National Kidney Foundation recommends that blood pressure levels be maintained at or below 130/80 mm Hg in anyone with diabetes or kidney disease.     

Hemoglobin A1c in Patients on Peritoneal Dialysis: How Should We Interpret It?

Almost half the patients on peritoneal dialysis are diabetic and glycemic control is essential to improve both patient and technique survival. Hemoglobin A1c (HbA1c) is widely used in the general population for diabetes diagnosis and monitoring as it highly correlates with blood glucose levels and outcomes. Its use has been extrapolated to the peritoneal dialysis population, despite HbA1c being commonly underestimated. In renal failure patients, HbA1c is influenced by variables affecting not only glycemia but also hemoglobin and the time of interaction between the two. Importantly, the impact of these variables differs in peritoneal dialysis compared to non‐dialysis chronic kidney disease and hemodialysis patients. Although HbA1c in peritoneal dialysis patients is less directly associated with blood glucose levels than in the general population, studies have confirmed its association with patient mortality. In this paper we review the variables that can influence HbA1c value emphasizing their impact in peritoneal dialysis patients. By providing clinicians with a comprehensive understanding of HbA1c results, we provide them with tools for a better patient management care and potential improved outcomes of peritoneal dialysis patients.