Evaluating the treatment of hypertension in diabetes mellitus: a need for better control?

Objectives To determine how well and to what extent blood pressure (BP) is controlled in diabetic hypertensive patients treated by primary care doctors, and to evaluate drug therapy in the backdrop of risk factors and laboratory findings. Methods A therapeutic audit of the medical records of diabetic hypertensives from nine primary care health centres in Bahrain. Results In 266 diabetic hypertensives (82 males and 184 females), the recommended target BP < 130/< 85 mmHg (WHO/ISH guidelines, 1999) was achieved in 20 (9.8%) with a BP of 119 ± 4/76 ± 5 mmHg. Among those who did not achieve target BP, 70 (34.5%) lacked systolic BP control (BP = 153 ± 17/79 ± 3 mmHg), four (2%) lacked diastolic BP control (BP = 123 ± 3/86 ± 3 mmHg) and 109 (53.7%) lacked both systolic and diastolic BP control (BP = 158 ± 20/94 ± 7 mmHg). The mean age of the group achieving target BP was significantly lower than the group which lacked systolic BP control (51.6 ± 9 vs. 63.5 ± 9 years; P < 0.0001). While there were no significant differences in fasting blood glucose, glycosylated haemoglobin, triglycerides, urea, creatinine, uric acid and serum electrolytes between the group achieving target BP vs. groups without target BP, a significant difference in total cholesterol was seen. Patients with ischaemic heart disease and/or isolated systolic hypertension did not achieve the target BP. Antihypertensive monotherapy was prescribed in 145 (54.5%) patients, whereas two‐ and three‐drug combinations were prescribed in 32.3 and 8.2% of patients, respectively. As monotherapy, angiotensin‐converting enzyme (ACE) inhibitors were the most frequently prescribed drugs followed by β‐blockers, calcium channel blockers (CCBs) and diuretics. As two‐drug combinations, an ACE inhibitor with a β‐blocker/diuretic and a β‐blocker with a CCB/diuretic were usually prescribed. Conclusions According to the WHO/ISH 1999 guidelines, approximately one out of 10 diabetic hypertensives achieved target BP control. In many instances, the drug therapy prescribed was inappropriate considering the comorbidity in patients and their laboratory findings. Improved BP control is needed in treating high‐risk groups such as patients with diabetes mellitus, and efforts should be made to improve the treatment of hypertension in the primary care setting.     

Pharmacotherapy and blood pressure control in elderly hypertensives in a primary care setting in Bahrain

BACKGROUND AND AIMS: Antihypertensive treatment in the elderly has important beneficial effects in terms of reduced cardiovascular morbidity and mortality. The aim of this study was to determine, in elderly hypertensives, the adherence of primary care physicians to World Health Organization/International Society of Hypertension (WHO/ISH) guidelines for the drug management of hypertension and extent of blood pressure (BP) control. METHODS: A multicentric therapeutic audit of medical records of elderly hypertensives was performed in nine primary care health centers in the Kingdom of Bahrain. RESULTS: In elderly hypertensives (> or =60 years), the WHO/ISH-1999 recommended BP targets of <140/<90 mmHg and BP<130/85 mmHg were achieved in 11.1% of elderly hypertensives and 4.1% of elderly diabetic hypertensives, respectively. Antihypertensive combination therapy was used in approximately half of the elderly. No significant difference in BP was found in elderly hypertensives treated either with monotherapy or combination therapy. As regards mono- and overall drug utilization, beta-blockers were the most frequently prescribed drugs in hypertensives, and angiotensin-converting enzyme (ACE) inhibitors in diabetic hypertensives. Diuretics and calcium channel blockers, the preferred antihypertensives for the elderly, were less often prescribed, particularly in patients with isolated systolic hypertension. CONCLUSIONS: Approximately one out of 9 elderly hypertensives and one out of 24 diabetic hypertensives achieved optimal BP control. Although preference for antihypertensives was markedly influenced by comorbidity with diabetes, tailoring of drug therapy was suboptimal and did not adhere to the recommended guidelines in elderly hypertensives. Efforts to improve the drug management of hypertension at primary care level, particularly in the elderly, are required.     

Platelet glycoprotein IIb/IIIa antagonists in clinical trials for the treatment of coronary artery disease

There is a growing understanding of the central role that platelets play in coronary artery disease. The glycoprotein IIb/IIIa receptor has recently been identified as the final common pathway for platelet aggregation and hence has been the focus of many clinical trials to influence various aspects of coronary artery disease. In this report we give an overview of these clinical trials.     

Comparison of women versus men hospitalized with heart failure (from a 20-year registry in a middle-eastern country 1991-2010)

The aim of the present study was to compare the clinical characteristics, treatment, and outcomes of women and men hospitalized with heart failure (HF) in a Middle-Eastern country. A retrospective analysis of all patients hospitalized with HF in the State of Qatar from 1991 through 2010 was made. The clinical characteristics, management, and outcomes of the patients with HF were compared according to gender. A subset analysis according to ethnicity was also done (Middle Eastern Arabs vs South Asians). During the 20-year period, 2,379 women and 4,689 men were hospitalized for HF. The women were older and more likely to have diabetes mellitus, hypertension, and chronic renal impairment compared to the male patients. The women were less likely to be current smokers and to have ischemic heart disease compared to the men. Impaired left ventricular function was more common among men. The in-hospital mortality rates were comparable between the 2 groups (7.7% in women vs 8.2% in men; p = 0.4) and significantly improved with time in the 2 groups (p = 0.001). The mortality rates were comparable among the women, regardless of the ethnicity. In conclusion, overall improvement occurred in survival in patients hospitalized with HF in a Middle-Eastern country, regardless of gender. Women hospitalized with HF had mortality rates comparable to those of men.     

Marital Status and Outcome of Patients Presenting with Acute Coronary Syndrome: An Observational Report

Background & hypothesis:

Data on the clinical characteristics and outcome of patients presenting with acute coronary syndrome (ACS) according to their marital status is not clear.

Methods:

A total of 5334 patients presenting with ACS in 65 hospitals in 6 Middle East countries in the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE‐2) were studied according to their marital status (5024 married, 100 single, and 210 widowed patients).

Result:

When compared to married patients, widowed patients were older and more likely to be female. Widowed patients were more likely to have diabetes mellitus, hypertension, history of heart failure, and peripheral vascular disease and were less likely to be tobacco users when compared to the other groups. Widowed patients were also more likely to present with atypical symptoms and have advanced Killip class. Widowed patients were more likely to present with non‐ST‐elevation myocardial infarction (NSTEMI) when compared to the other 2 groups. Widowed patients were more likely to have heart failure (P = 0.001), cardiogenic shock (P = 0.001), and major bleeding (P = 0.002) when compared to the other groups. No statistically significant difference was observed in regard to duration of hospital stay, door to needle time in STEMI patients, or cardiac arrhythmias between the various groups. Widowed patients had higher in‐hospital, 30‐day, and 1‐year mortality rates (P = 0.001). Marital status was an independent predictor for in‐hospital mortality.

Conclusion:

Widowed marital status was associated with worse cardiovascular risk profile, and worse in‐hospital and 1‐year outcome. Future work should be focused on whether the provision of psychosocial support will result in improved outcomes among this high‐risk group. Clin. Cardiol. 2011 DOI: 10.1002/clc.22034 Gulf RACE is a Gulf Heart Association (GHA) project and was financially supported by the GHA, Sanofi Aventis, and the College of Medicine Research Center at King Khalid University Hospital, King Saud University, and Riyadh, Saudi Arabia. The authors have no other funding, financial relationships, or conflicts of interest to disclose.     

Multiple coronary artery thrombosis in a 41-year-old male patient presenting with ST-segment elevation myocardial infarction

Simultaneous occlusion of multiple epicardial coronary arteries is an uncommon finding in patients presenting with ST-segment elevation myocardial infarction (STEMI). We describe a 41- year-old male Asian patient who presented with inferior and anterior STEMI complicated by cardiogenic shock and frequent life-threatening ventricular arrhythmias. The patient was subsequently found to have acute occlusion of the proximal right coronary artery (RCA) and proximal left anterior descending coronary artery (LAD). The patient was treated with primary percutaneous coronary interventions for RCA and LAD, and intra-aortic balloon pump placement showed excellent results. Based on the available literature, early PCI for this very rare condition is paramount for patient survival.     

Maternal and perinatal outcome of eclampsia over a decade at a tertiary hospital in Kuwait

Aims: To determine maternal and perinatal outcome of eclampsia patients over a decade.

Methods: Analysis of case records of all eclampsia cases from January 2005 to December 2014.

Results: There were 30 cases of eclampsia. The most significant risk factors for developing pre-eclampsia are unbooked cases (97%), nulliparity, young age, marriage?≤4 months, history of pre-eclampsia in previous pregnancy, remarriage, preexisting diabetes mellitus, interval between pregnancies?≥10 years, positive family history. The incidence of eclampsia was 0.05%, antepartum eclampsia 15 (50%), intrapartum 6 (20%) and postpartum 9 (30%) with no maternal deaths, and 1 perinatal death. Perinatal mortality was 33.3/1000. 22 (73%) patients received magnesium sulphate (MgSO₄) and 8 patients (27%) received Diazepam, of which 1 had recurrence of convulsions. All 15 antepartum cases were delivered by cesarean section as were 2 intrapartum. 13 (43%) of women delivered vaginally. Only 6 (20%) patients were of low socio-economic status and were primary school educated. Severe maternal complications occurred in 8 (27%), with abruptio placentae being the most common 3 (38%).

Conclusions: Incidence of eclampsia was low, with no maternal deaths. MgSO4 was found to be highly effective. Lack of antenatal care is a major risk factor.     

Field validation of a competitive ELISA for detection of <Emphasis Type="Italic">Theileria annulata</Emphasis> infection

In previous studies, Theileria annulata surface protein (TaSP) was identified as an immunodominant antigen and successfully used to develop a recombinant-protein-based indirect enzyme-linked immunosorbent assay (ELISA) for the detection of circulating antibodies in serum of T. annulata-infected animals. To increase the specificity, a competitive ELISA (cELISA) was developed using recombinant TaSP antigen and a monoclonal antibody (1C7) specifically binding to TaSP. Since the cELISA accurately differentiated T. annulata-infected from uninfected animals, a study was performed to analyse the suitability of the cELISA in the field. For this, 230 sera with unknown status from different governorates in the north of Iraq were analysed using both the indirect and competitive ELISA and were compared. There was a significant (p < 0.5 × 10⁻¹⁹) correlation (r = 0.556) between the tests, whereby the cELISA detected more sera as negative (44/230) compared to the indirect ELISA (21/270). Accordingly, less sera were determined to be positive in the competitive (186/230) than in the indirect ELISA (209/230). Sensitivity and specificity of the cELISA taking the indirect ELISA as a reference were 84.2% and 52.4%, respectively. Accordingly, the calculated prevalence of T. annulata infection was 90.9%, and the positive predictive value was determined to be 94.6%. Taken together, the cELISA proved its suitability for field application and was found qualified for use in serological surveys to monitor the prevalence of T. annulata infection and to identify carrier animals.