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GPs Urged to Embed Lifestyle Medicine into Primary Care
LIVERPOOL — “Healthy doctors make healthy patients”, stated a GP during a workshop at the Royal College of General Practitioners (RCGP) annual meeting. The session aimed to encourage GPs to embed lifestyle medicine into primary care through collaborative action.
Callum Leese from Aberfeldy Medical Practice in Scotland, who is also a lecturer at the University of Dundee for the Scottish Clinical Research Excellence Development Scheme (SCREDS), discussed the benefits of lifestyle medicine services in addressing lifestyle-related diseases, reducing their contribution towards the prevalence of chronic conditions, and helping prevent premature mortality.
Leese is leading a project to make Aberfeldy the healthiest town in Scotland by promoting physical activities, such as the 2-km, 5-km, and 7-km Santa Stride walking group in November, and a recent food festival to encourage healthy cooking and eating. “There’s loads of things that can be done to try and inspire change,” he said. “The research is fairly unequivocal in that healthy doctors make healthy patients,” Leese asserted. “The most important thing we can do is target our doctors and our nurses and make them advocates for what we want to see with our patients.”
Speaking to this news organization, he emphasized that, “if the doctors are moving, they’re much more likely to promote it, and if they’re eating well, they’re much more likely to be able to be evangelistic.”
Physical Activity Advice Shows High Return
About one-third of the population in the United Kingdom are physically inactive, which costs the economy £7.2 billion, with £1 billion attributed directly to the NHS, he informed the workshop.
As an honorary support fellow in physical activity and lifestyle medicine at the RCGP, Leese specializes in integrating physical activity into primary care settings. “We know it’s cost effective. If we compare it to smoking cessation advice, we know that we need to give advice to one person about 50 times for one person to stop smoking in primary care. But for physical activity, you need to give advice to 12 people for one person to increase their physical activity levels to meet the guidance,” he noted.
Leese stressed the importance of short but effective discussions between GPs and patients. He gave examples of online resources to recommend to patients, such as Moving Medicine, which aims to help healthcare professionals integrate physical activity into routine clinical conversations, or the RCGP toolkit (the Physical Activity Hub). “It really takes 1 minute of asking if the patient has ever considered being more active, and briefly explaining that being more active might have really significant outcomes for their condition,” he said.
In primary care, most patients who need to be more physically activity are directed toward 12-week exercise referral schemes, and sometimes we use social prescribing, for example, inviting patients to walk in groups, Leese explained. “However, despite the best intentions, about 78% of GPs aren’t doing it [advising on physical activity] regularly,” he noted. He cited four main challenges: lack of time, knowledge, resources, and financial support.
Geographical Variation in Social Prescribing
Social prescribing, which links patients with non–medical community support, also varies widely across the United Kingdom. “Social prescribing is a real example of that because it’s really well established in some places and not in others,” Leese remarked. He noted that inner-city and rural areas often have different needs. Contrary to some expectations, city dwellers are sometimes more active than those living in rural areas because despite having lots of green space for physical activity, “they tend to park the car outside the front door and park again right outside their place of work, whereas in London, for example, you can persuade people to get off a stop early on the Tube or a stop early in the bus.”
MAN v FAT 5-a-side Football
Leese also emphasized the importance of innovation in implementing lifestyle medicine, pointing out that nonmedical personnel, social prescribers, and health coaches can alleviate time pressures on GPs.
Citing an example of a physical activity-related intervention, he described a UK-wide organization developed for men in the 40s-50s age group, called MAN v FAT, which involves a novel weight-related way of playing five-a-side football. Players have a weigh-in before each game and teams are rewarded with points on the pitch for every pound lost as a team since their last match.
However, Leese acknowledged the need to tailor physical activity advice to different age groups. For example, “in an 80-year-old, physical activity might improve their balance and they’re less likely to fall and break something.”
Lifestyle Clinics
Leese cited the PCN Lifestyle Clinics, originating from the Leamington Primary Care Network (PCN), as an example of successful lifestyle medicine integration to help address the needs of people living with chronic conditions. “We don’t want to prescribe a model, but we can draw on a program run by the Leamington Spa PCN, that involves four group sessions of 6-10 people focused on lifestyle,” he said.
The weekly group-based sessions are run by a GP, a health and wellbeing coach, a dietitian, and a psychiatrist. Together, they cover four aspects of lifestyle and health comprising individual challenges, how community influences behavior and vice versa, food and nutrition, and physical activity for health and wellbeing.
“We try to debunk some of those myths around nutrition, compared with diet, and physical activity, compared with exercise. So, for example, the idea that exercise is usually considered to be using an elliptical cross-trainer whereas physical activity, which might be just dancing in your kitchen while you’re making dinner, is something that can be done more easily,” explained Leese.
Physical activities include running and swimming in collaboration with a leisure center. “It’s an amazing program,” he remarked.
Outcomes from 142 patients who attended the Lifestyle Clinic at a North Leamington GP practice over 14 months showed that 53% gained confidence in making lifestyle changes, 60% noticed a positive impact on their physical health, and 77% reported positive impacts on their mental health.
GP Embraces Lifestyle Medicine
Rachel Burnett, a GP from Park Medical Practice in Derby, a delegate who attended the session, commented on the central idea of incorporating lifestyle medicine into primary care practice. She told this news organization that, “I think it could prevent a lot of ill health and therefore a lot of health inequalities just by embedding lifestyle medicine into our work. To hear about the Leamington Spa project and how it›s been a success was really inspiring.”
Referring to her own practice, Burnett said: “My patients are familiar with the way I go on and on about lifestyle measures, but I believe the way forward is with group sessions because we need to give the same advice to a large number of patients, for example, with prediabetes. This could save time and resource, and I think patients who are more likely to make the changes will actually attend the sessions so we’re not wasting our breath.”
Neither Leese nor Burnett declared any relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
LIVERPOOL — “Healthy doctors make healthy patients”, stated a GP during a workshop at the Royal College of General Practitioners (RCGP) annual meeting. The session aimed to encourage GPs to embed lifestyle medicine into primary care through collaborative action.
Callum Leese from Aberfeldy Medical Practice in Scotland, who is also a lecturer at the University of Dundee for the Scottish Clinical Research Excellence Development Scheme (SCREDS), discussed the benefits of lifestyle medicine services in addressing lifestyle-related diseases, reducing their contribution towards the prevalence of chronic conditions, and helping prevent premature mortality.
Leese is leading a project to make Aberfeldy the healthiest town in Scotland by promoting physical activities, such as the 2-km, 5-km, and 7-km Santa Stride walking group in November, and a recent food festival to encourage healthy cooking and eating. “There’s loads of things that can be done to try and inspire change,” he said. “The research is fairly unequivocal in that healthy doctors make healthy patients,” Leese asserted. “The most important thing we can do is target our doctors and our nurses and make them advocates for what we want to see with our patients.”
Speaking to this news organization, he emphasized that, “if the doctors are moving, they’re much more likely to promote it, and if they’re eating well, they’re much more likely to be able to be evangelistic.”
Physical Activity Advice Shows High Return
About one-third of the population in the United Kingdom are physically inactive, which costs the economy £7.2 billion, with £1 billion attributed directly to the NHS, he informed the workshop.
As an honorary support fellow in physical activity and lifestyle medicine at the RCGP, Leese specializes in integrating physical activity into primary care settings. “We know it’s cost effective. If we compare it to smoking cessation advice, we know that we need to give advice to one person about 50 times for one person to stop smoking in primary care. But for physical activity, you need to give advice to 12 people for one person to increase their physical activity levels to meet the guidance,” he noted.
Leese stressed the importance of short but effective discussions between GPs and patients. He gave examples of online resources to recommend to patients, such as Moving Medicine, which aims to help healthcare professionals integrate physical activity into routine clinical conversations, or the RCGP toolkit (the Physical Activity Hub). “It really takes 1 minute of asking if the patient has ever considered being more active, and briefly explaining that being more active might have really significant outcomes for their condition,” he said.
In primary care, most patients who need to be more physically activity are directed toward 12-week exercise referral schemes, and sometimes we use social prescribing, for example, inviting patients to walk in groups, Leese explained. “However, despite the best intentions, about 78% of GPs aren’t doing it [advising on physical activity] regularly,” he noted. He cited four main challenges: lack of time, knowledge, resources, and financial support.
Geographical Variation in Social Prescribing
Social prescribing, which links patients with non–medical community support, also varies widely across the United Kingdom. “Social prescribing is a real example of that because it’s really well established in some places and not in others,” Leese remarked. He noted that inner-city and rural areas often have different needs. Contrary to some expectations, city dwellers are sometimes more active than those living in rural areas because despite having lots of green space for physical activity, “they tend to park the car outside the front door and park again right outside their place of work, whereas in London, for example, you can persuade people to get off a stop early on the Tube or a stop early in the bus.”
MAN v FAT 5-a-side Football
Leese also emphasized the importance of innovation in implementing lifestyle medicine, pointing out that nonmedical personnel, social prescribers, and health coaches can alleviate time pressures on GPs.
Citing an example of a physical activity-related intervention, he described a UK-wide organization developed for men in the 40s-50s age group, called MAN v FAT, which involves a novel weight-related way of playing five-a-side football. Players have a weigh-in before each game and teams are rewarded with points on the pitch for every pound lost as a team since their last match.
However, Leese acknowledged the need to tailor physical activity advice to different age groups. For example, “in an 80-year-old, physical activity might improve their balance and they’re less likely to fall and break something.”
Lifestyle Clinics
Leese cited the PCN Lifestyle Clinics, originating from the Leamington Primary Care Network (PCN), as an example of successful lifestyle medicine integration to help address the needs of people living with chronic conditions. “We don’t want to prescribe a model, but we can draw on a program run by the Leamington Spa PCN, that involves four group sessions of 6-10 people focused on lifestyle,” he said.
The weekly group-based sessions are run by a GP, a health and wellbeing coach, a dietitian, and a psychiatrist. Together, they cover four aspects of lifestyle and health comprising individual challenges, how community influences behavior and vice versa, food and nutrition, and physical activity for health and wellbeing.
“We try to debunk some of those myths around nutrition, compared with diet, and physical activity, compared with exercise. So, for example, the idea that exercise is usually considered to be using an elliptical cross-trainer whereas physical activity, which might be just dancing in your kitchen while you’re making dinner, is something that can be done more easily,” explained Leese.
Physical activities include running and swimming in collaboration with a leisure center. “It’s an amazing program,” he remarked.
Outcomes from 142 patients who attended the Lifestyle Clinic at a North Leamington GP practice over 14 months showed that 53% gained confidence in making lifestyle changes, 60% noticed a positive impact on their physical health, and 77% reported positive impacts on their mental health.
GP Embraces Lifestyle Medicine
Rachel Burnett, a GP from Park Medical Practice in Derby, a delegate who attended the session, commented on the central idea of incorporating lifestyle medicine into primary care practice. She told this news organization that, “I think it could prevent a lot of ill health and therefore a lot of health inequalities just by embedding lifestyle medicine into our work. To hear about the Leamington Spa project and how it›s been a success was really inspiring.”
Referring to her own practice, Burnett said: “My patients are familiar with the way I go on and on about lifestyle measures, but I believe the way forward is with group sessions because we need to give the same advice to a large number of patients, for example, with prediabetes. This could save time and resource, and I think patients who are more likely to make the changes will actually attend the sessions so we’re not wasting our breath.”
Neither Leese nor Burnett declared any relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
LIVERPOOL — “Healthy doctors make healthy patients”, stated a GP during a workshop at the Royal College of General Practitioners (RCGP) annual meeting. The session aimed to encourage GPs to embed lifestyle medicine into primary care through collaborative action.
Callum Leese from Aberfeldy Medical Practice in Scotland, who is also a lecturer at the University of Dundee for the Scottish Clinical Research Excellence Development Scheme (SCREDS), discussed the benefits of lifestyle medicine services in addressing lifestyle-related diseases, reducing their contribution towards the prevalence of chronic conditions, and helping prevent premature mortality.
Leese is leading a project to make Aberfeldy the healthiest town in Scotland by promoting physical activities, such as the 2-km, 5-km, and 7-km Santa Stride walking group in November, and a recent food festival to encourage healthy cooking and eating. “There’s loads of things that can be done to try and inspire change,” he said. “The research is fairly unequivocal in that healthy doctors make healthy patients,” Leese asserted. “The most important thing we can do is target our doctors and our nurses and make them advocates for what we want to see with our patients.”
Speaking to this news organization, he emphasized that, “if the doctors are moving, they’re much more likely to promote it, and if they’re eating well, they’re much more likely to be able to be evangelistic.”
Physical Activity Advice Shows High Return
About one-third of the population in the United Kingdom are physically inactive, which costs the economy £7.2 billion, with £1 billion attributed directly to the NHS, he informed the workshop.
As an honorary support fellow in physical activity and lifestyle medicine at the RCGP, Leese specializes in integrating physical activity into primary care settings. “We know it’s cost effective. If we compare it to smoking cessation advice, we know that we need to give advice to one person about 50 times for one person to stop smoking in primary care. But for physical activity, you need to give advice to 12 people for one person to increase their physical activity levels to meet the guidance,” he noted.
Leese stressed the importance of short but effective discussions between GPs and patients. He gave examples of online resources to recommend to patients, such as Moving Medicine, which aims to help healthcare professionals integrate physical activity into routine clinical conversations, or the RCGP toolkit (the Physical Activity Hub). “It really takes 1 minute of asking if the patient has ever considered being more active, and briefly explaining that being more active might have really significant outcomes for their condition,” he said.
In primary care, most patients who need to be more physically activity are directed toward 12-week exercise referral schemes, and sometimes we use social prescribing, for example, inviting patients to walk in groups, Leese explained. “However, despite the best intentions, about 78% of GPs aren’t doing it [advising on physical activity] regularly,” he noted. He cited four main challenges: lack of time, knowledge, resources, and financial support.
Geographical Variation in Social Prescribing
Social prescribing, which links patients with non–medical community support, also varies widely across the United Kingdom. “Social prescribing is a real example of that because it’s really well established in some places and not in others,” Leese remarked. He noted that inner-city and rural areas often have different needs. Contrary to some expectations, city dwellers are sometimes more active than those living in rural areas because despite having lots of green space for physical activity, “they tend to park the car outside the front door and park again right outside their place of work, whereas in London, for example, you can persuade people to get off a stop early on the Tube or a stop early in the bus.”
MAN v FAT 5-a-side Football
Leese also emphasized the importance of innovation in implementing lifestyle medicine, pointing out that nonmedical personnel, social prescribers, and health coaches can alleviate time pressures on GPs.
Citing an example of a physical activity-related intervention, he described a UK-wide organization developed for men in the 40s-50s age group, called MAN v FAT, which involves a novel weight-related way of playing five-a-side football. Players have a weigh-in before each game and teams are rewarded with points on the pitch for every pound lost as a team since their last match.
However, Leese acknowledged the need to tailor physical activity advice to different age groups. For example, “in an 80-year-old, physical activity might improve their balance and they’re less likely to fall and break something.”
Lifestyle Clinics
Leese cited the PCN Lifestyle Clinics, originating from the Leamington Primary Care Network (PCN), as an example of successful lifestyle medicine integration to help address the needs of people living with chronic conditions. “We don’t want to prescribe a model, but we can draw on a program run by the Leamington Spa PCN, that involves four group sessions of 6-10 people focused on lifestyle,” he said.
The weekly group-based sessions are run by a GP, a health and wellbeing coach, a dietitian, and a psychiatrist. Together, they cover four aspects of lifestyle and health comprising individual challenges, how community influences behavior and vice versa, food and nutrition, and physical activity for health and wellbeing.
“We try to debunk some of those myths around nutrition, compared with diet, and physical activity, compared with exercise. So, for example, the idea that exercise is usually considered to be using an elliptical cross-trainer whereas physical activity, which might be just dancing in your kitchen while you’re making dinner, is something that can be done more easily,” explained Leese.
Physical activities include running and swimming in collaboration with a leisure center. “It’s an amazing program,” he remarked.
Outcomes from 142 patients who attended the Lifestyle Clinic at a North Leamington GP practice over 14 months showed that 53% gained confidence in making lifestyle changes, 60% noticed a positive impact on their physical health, and 77% reported positive impacts on their mental health.
GP Embraces Lifestyle Medicine
Rachel Burnett, a GP from Park Medical Practice in Derby, a delegate who attended the session, commented on the central idea of incorporating lifestyle medicine into primary care practice. She told this news organization that, “I think it could prevent a lot of ill health and therefore a lot of health inequalities just by embedding lifestyle medicine into our work. To hear about the Leamington Spa project and how it›s been a success was really inspiring.”
Referring to her own practice, Burnett said: “My patients are familiar with the way I go on and on about lifestyle measures, but I believe the way forward is with group sessions because we need to give the same advice to a large number of patients, for example, with prediabetes. This could save time and resource, and I think patients who are more likely to make the changes will actually attend the sessions so we’re not wasting our breath.”
Neither Leese nor Burnett declared any relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
Caffeine Brings Benefits and Risks
Coffee and tea are among the plants that are highest in caffeine. Their use as beverages makes caffeine the most consumed psychoactive agent in the world. Coffee is commonly used to increase alertness and work productivity. Synthetic caffeine is added to soft drinks, energy drinks, and products intended to reduce fatigue or promote weight loss.
The caffeine content varies with the type of drink: It is high in coffee, energy drinks, and caffeine tablets; intermediate in tea; and low in soft drinks. Coffee is the predominant source of the caffeine ingested by adults. The evidence for caffeine’s effects on people is ambiguous, and some risks and benefits deserve special attention because of the impact they may have on our health.
Characteristics of Caffeine
The half-life of caffeine varies according to age. In adults, it is 2.5-4.5 hours; in newborns, 80 hours; in children older than 6 months, it remains stable over time with respect to weight. Smoking accelerates caffeine metabolism by reducing the half-life by 50%. Oral contraceptives, however, double caffeine’s half-life. Caffeine metabolism is reduced during pregnancy (it is greater in the first trimester), with a half-life of more than 15 hours. Caffeine clearance can be slowed by several classes of drugs (eg, quinolones, cardiovascular drugs, bronchodilators, and antidepressants) that increase its half-life because they are metabolized by the same liver enzymes.
Caffeine passes the blood-brain barrier and, having an adenosine-like structure, inhibits adenosine’s effects by binding to adenosine receptors. In the brain, caffeine reduces fatigue, increases alertness, reduces reaction times, may reduce the risk for depression, and increases the effectiveness of nonsteroidal anti-inflammatory drugs in treating headaches and other types of pain.
Caffeine and Chronic Diseases
The evidence available on the relationship between caffeine and health has several methodological limitations. Observations of the acute effects of caffeine may not reflect long-term effects because tolerance to caffeine’s effects may develop over time. Smoking and unhealthy lifestyles are confounding factors in epidemiological studies of caffeine intake. In addition, the estimate of the amount and frequency of caffeine intake is often inaccurate because it is mainly based on self-assessment systems. Finally, prospective studies of caffeine consumption are mainly based on coffee and tea consumption, but it is unclear how much the observed outcomes can be translated to intake of other beverages such as energy drinks.
Considering the very high prevalence of arterial hypertension worldwide (31.1% of adults), many questions have been raised about the influence of coffee consumption on blood pressure (BP) and the risk for arterial hypertension. Administration of 200-300 mg caffeine is shown to induce a mean increase of 8.1 mm Hg systolic BP and 5.7 mm Hg diastolic BP. The increase is observed in the first hour after caffeine intake and lasts no longer than 3 hours.
Yet, the moderate and usual consumption of coffee does not increase, but may even reduce, the risk of developing high BP. In contrast, occasional coffee consumption can have hypertensive effects, and moderate and usual consumption in patients with high BP does not appear to increase the risk for uncontrolled BP and can reduce the risk for death from any cause. The inverse association between coffee consumption and hypertension risk was confirmed in a review and meta-analysis of cross-sectional and cohort studies.
With respect to lipid metabolism, cholesterol levels may increase after caffeine consumption because of cafestol. Concentrations of cafestol are high in unfiltered coffee, intermediate in espresso and moka pot coffee, and negligible in instant or filtered coffee. Studies on the impact of coffee on lipid levels have led to inconsistent results, however. Data have shown that people who drink more coffee have higher triglycerides, total cholesterol, and low-density lipoprotein cholesterol (LDL-C) levels. Other data have shown that caffeine promotes LDL receptor expression and clearance of LDL cholesterol.
Experimental and cohort studies have not shown an association between coffee consumption and atrial fibrillation (AF). In fact, evidence suggests that coffee consumption tends to reduce the risk for AF in a dose-response relationship. Similarly, coffee consumption is not associated with increased risk for cardiovascular events in the general population or among patients with a history of hypertension, diabetes, or cardiovascular disease.
The Coffee and Real-Time Atrial and Ventricular Ectopy study evaluated the acute effects of coffee consumption on cardiac ectopy using wearable sensors with continuous recording. It did not demonstrate any increase in daily premature atrial contractions with coffee consumption, compared with abstaining from caffeine.
In patients with type 2 diabetes, a study performed in Japan showed that coffee consumption was associated with reduced all-cause mortality. The results suggested a dose-response relationship, and drinking coffee and green tea appeared to reduce mortality risk further. The results were not generalizable, however, because of the study population’s ethnic homogeneity.
Dose and Toxicity
Caffeine at high doses (> 400 mg daily) and in susceptible patients can induce anxiety, but the effects of caffeine on sleep and anxiety can differ from patient to patient. This variation reflects differences in caffeine metabolism rate and adenosine receptor gene variants.
High caffeine intake can stimulate diuresis, but without causing damaging effects on hydration when taking moderate doses of caffeine (≤ 400 mg daily) for long periods. Stopping caffeine suddenly, in a regular consumer, can lead to withdrawal symptoms such as headache, asthenia, decreased attention, depressed mood, and flu-like symptoms.
The toxic effects of caffeine occur with intake > 1.2 g. A dose of 10-14 g is considered fatal. Caffeine overdose is rare when considering traditional methods of intake (coffee and tea) because 70-100 cups of coffee should be sufficient for caffeine poisoning. Severe events can occur following the use of caffeine tablets or as energy drinks for the following reasons:
- The episodic consumption of caffeine does not allow for tolerance to develop.
- Young people are more vulnerable to the effects of caffeine.
- Caffeine has a synergistic effect in combination with other components in energy drinks.
- Taking caffeine in combination with alcohol or intense exertion causes serious, even fatal, outcomes.
Products Containing Caffeine
Evidence supports the relationship between high consumption (approximately 1 L) of energy drinks with a caffeine content of 320 mg and short-term cardiovascular adverse events, such as increased BP, QT-segment prolongation corrected for heart rate, and palpitations. These tests prompt the recommendation to avoid consuming these beverages in high quantities and in association with alcohol.
Weight loss products generally contain caffeine coupled with herbal extracts that are expected to improve fat metabolism, lipolysis, and oxidation. These products, because of their easy availability, presumed benefits, and high caffeine concentration, may be more susceptible to misuse because they can be taken in larger portions than recommended. The combination of multiple ingredients, concentrated amounts of caffeine, and excessive consumption increases the likelihood of adverse effects.
This story was translated from Univadis Italy, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
Coffee and tea are among the plants that are highest in caffeine. Their use as beverages makes caffeine the most consumed psychoactive agent in the world. Coffee is commonly used to increase alertness and work productivity. Synthetic caffeine is added to soft drinks, energy drinks, and products intended to reduce fatigue or promote weight loss.
The caffeine content varies with the type of drink: It is high in coffee, energy drinks, and caffeine tablets; intermediate in tea; and low in soft drinks. Coffee is the predominant source of the caffeine ingested by adults. The evidence for caffeine’s effects on people is ambiguous, and some risks and benefits deserve special attention because of the impact they may have on our health.
Characteristics of Caffeine
The half-life of caffeine varies according to age. In adults, it is 2.5-4.5 hours; in newborns, 80 hours; in children older than 6 months, it remains stable over time with respect to weight. Smoking accelerates caffeine metabolism by reducing the half-life by 50%. Oral contraceptives, however, double caffeine’s half-life. Caffeine metabolism is reduced during pregnancy (it is greater in the first trimester), with a half-life of more than 15 hours. Caffeine clearance can be slowed by several classes of drugs (eg, quinolones, cardiovascular drugs, bronchodilators, and antidepressants) that increase its half-life because they are metabolized by the same liver enzymes.
Caffeine passes the blood-brain barrier and, having an adenosine-like structure, inhibits adenosine’s effects by binding to adenosine receptors. In the brain, caffeine reduces fatigue, increases alertness, reduces reaction times, may reduce the risk for depression, and increases the effectiveness of nonsteroidal anti-inflammatory drugs in treating headaches and other types of pain.
Caffeine and Chronic Diseases
The evidence available on the relationship between caffeine and health has several methodological limitations. Observations of the acute effects of caffeine may not reflect long-term effects because tolerance to caffeine’s effects may develop over time. Smoking and unhealthy lifestyles are confounding factors in epidemiological studies of caffeine intake. In addition, the estimate of the amount and frequency of caffeine intake is often inaccurate because it is mainly based on self-assessment systems. Finally, prospective studies of caffeine consumption are mainly based on coffee and tea consumption, but it is unclear how much the observed outcomes can be translated to intake of other beverages such as energy drinks.
Considering the very high prevalence of arterial hypertension worldwide (31.1% of adults), many questions have been raised about the influence of coffee consumption on blood pressure (BP) and the risk for arterial hypertension. Administration of 200-300 mg caffeine is shown to induce a mean increase of 8.1 mm Hg systolic BP and 5.7 mm Hg diastolic BP. The increase is observed in the first hour after caffeine intake and lasts no longer than 3 hours.
Yet, the moderate and usual consumption of coffee does not increase, but may even reduce, the risk of developing high BP. In contrast, occasional coffee consumption can have hypertensive effects, and moderate and usual consumption in patients with high BP does not appear to increase the risk for uncontrolled BP and can reduce the risk for death from any cause. The inverse association between coffee consumption and hypertension risk was confirmed in a review and meta-analysis of cross-sectional and cohort studies.
With respect to lipid metabolism, cholesterol levels may increase after caffeine consumption because of cafestol. Concentrations of cafestol are high in unfiltered coffee, intermediate in espresso and moka pot coffee, and negligible in instant or filtered coffee. Studies on the impact of coffee on lipid levels have led to inconsistent results, however. Data have shown that people who drink more coffee have higher triglycerides, total cholesterol, and low-density lipoprotein cholesterol (LDL-C) levels. Other data have shown that caffeine promotes LDL receptor expression and clearance of LDL cholesterol.
Experimental and cohort studies have not shown an association between coffee consumption and atrial fibrillation (AF). In fact, evidence suggests that coffee consumption tends to reduce the risk for AF in a dose-response relationship. Similarly, coffee consumption is not associated with increased risk for cardiovascular events in the general population or among patients with a history of hypertension, diabetes, or cardiovascular disease.
The Coffee and Real-Time Atrial and Ventricular Ectopy study evaluated the acute effects of coffee consumption on cardiac ectopy using wearable sensors with continuous recording. It did not demonstrate any increase in daily premature atrial contractions with coffee consumption, compared with abstaining from caffeine.
In patients with type 2 diabetes, a study performed in Japan showed that coffee consumption was associated with reduced all-cause mortality. The results suggested a dose-response relationship, and drinking coffee and green tea appeared to reduce mortality risk further. The results were not generalizable, however, because of the study population’s ethnic homogeneity.
Dose and Toxicity
Caffeine at high doses (> 400 mg daily) and in susceptible patients can induce anxiety, but the effects of caffeine on sleep and anxiety can differ from patient to patient. This variation reflects differences in caffeine metabolism rate and adenosine receptor gene variants.
High caffeine intake can stimulate diuresis, but without causing damaging effects on hydration when taking moderate doses of caffeine (≤ 400 mg daily) for long periods. Stopping caffeine suddenly, in a regular consumer, can lead to withdrawal symptoms such as headache, asthenia, decreased attention, depressed mood, and flu-like symptoms.
The toxic effects of caffeine occur with intake > 1.2 g. A dose of 10-14 g is considered fatal. Caffeine overdose is rare when considering traditional methods of intake (coffee and tea) because 70-100 cups of coffee should be sufficient for caffeine poisoning. Severe events can occur following the use of caffeine tablets or as energy drinks for the following reasons:
- The episodic consumption of caffeine does not allow for tolerance to develop.
- Young people are more vulnerable to the effects of caffeine.
- Caffeine has a synergistic effect in combination with other components in energy drinks.
- Taking caffeine in combination with alcohol or intense exertion causes serious, even fatal, outcomes.
Products Containing Caffeine
Evidence supports the relationship between high consumption (approximately 1 L) of energy drinks with a caffeine content of 320 mg and short-term cardiovascular adverse events, such as increased BP, QT-segment prolongation corrected for heart rate, and palpitations. These tests prompt the recommendation to avoid consuming these beverages in high quantities and in association with alcohol.
Weight loss products generally contain caffeine coupled with herbal extracts that are expected to improve fat metabolism, lipolysis, and oxidation. These products, because of their easy availability, presumed benefits, and high caffeine concentration, may be more susceptible to misuse because they can be taken in larger portions than recommended. The combination of multiple ingredients, concentrated amounts of caffeine, and excessive consumption increases the likelihood of adverse effects.
This story was translated from Univadis Italy, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
Coffee and tea are among the plants that are highest in caffeine. Their use as beverages makes caffeine the most consumed psychoactive agent in the world. Coffee is commonly used to increase alertness and work productivity. Synthetic caffeine is added to soft drinks, energy drinks, and products intended to reduce fatigue or promote weight loss.
The caffeine content varies with the type of drink: It is high in coffee, energy drinks, and caffeine tablets; intermediate in tea; and low in soft drinks. Coffee is the predominant source of the caffeine ingested by adults. The evidence for caffeine’s effects on people is ambiguous, and some risks and benefits deserve special attention because of the impact they may have on our health.
Characteristics of Caffeine
The half-life of caffeine varies according to age. In adults, it is 2.5-4.5 hours; in newborns, 80 hours; in children older than 6 months, it remains stable over time with respect to weight. Smoking accelerates caffeine metabolism by reducing the half-life by 50%. Oral contraceptives, however, double caffeine’s half-life. Caffeine metabolism is reduced during pregnancy (it is greater in the first trimester), with a half-life of more than 15 hours. Caffeine clearance can be slowed by several classes of drugs (eg, quinolones, cardiovascular drugs, bronchodilators, and antidepressants) that increase its half-life because they are metabolized by the same liver enzymes.
Caffeine passes the blood-brain barrier and, having an adenosine-like structure, inhibits adenosine’s effects by binding to adenosine receptors. In the brain, caffeine reduces fatigue, increases alertness, reduces reaction times, may reduce the risk for depression, and increases the effectiveness of nonsteroidal anti-inflammatory drugs in treating headaches and other types of pain.
Caffeine and Chronic Diseases
The evidence available on the relationship between caffeine and health has several methodological limitations. Observations of the acute effects of caffeine may not reflect long-term effects because tolerance to caffeine’s effects may develop over time. Smoking and unhealthy lifestyles are confounding factors in epidemiological studies of caffeine intake. In addition, the estimate of the amount and frequency of caffeine intake is often inaccurate because it is mainly based on self-assessment systems. Finally, prospective studies of caffeine consumption are mainly based on coffee and tea consumption, but it is unclear how much the observed outcomes can be translated to intake of other beverages such as energy drinks.
Considering the very high prevalence of arterial hypertension worldwide (31.1% of adults), many questions have been raised about the influence of coffee consumption on blood pressure (BP) and the risk for arterial hypertension. Administration of 200-300 mg caffeine is shown to induce a mean increase of 8.1 mm Hg systolic BP and 5.7 mm Hg diastolic BP. The increase is observed in the first hour after caffeine intake and lasts no longer than 3 hours.
Yet, the moderate and usual consumption of coffee does not increase, but may even reduce, the risk of developing high BP. In contrast, occasional coffee consumption can have hypertensive effects, and moderate and usual consumption in patients with high BP does not appear to increase the risk for uncontrolled BP and can reduce the risk for death from any cause. The inverse association between coffee consumption and hypertension risk was confirmed in a review and meta-analysis of cross-sectional and cohort studies.
With respect to lipid metabolism, cholesterol levels may increase after caffeine consumption because of cafestol. Concentrations of cafestol are high in unfiltered coffee, intermediate in espresso and moka pot coffee, and negligible in instant or filtered coffee. Studies on the impact of coffee on lipid levels have led to inconsistent results, however. Data have shown that people who drink more coffee have higher triglycerides, total cholesterol, and low-density lipoprotein cholesterol (LDL-C) levels. Other data have shown that caffeine promotes LDL receptor expression and clearance of LDL cholesterol.
Experimental and cohort studies have not shown an association between coffee consumption and atrial fibrillation (AF). In fact, evidence suggests that coffee consumption tends to reduce the risk for AF in a dose-response relationship. Similarly, coffee consumption is not associated with increased risk for cardiovascular events in the general population or among patients with a history of hypertension, diabetes, or cardiovascular disease.
The Coffee and Real-Time Atrial and Ventricular Ectopy study evaluated the acute effects of coffee consumption on cardiac ectopy using wearable sensors with continuous recording. It did not demonstrate any increase in daily premature atrial contractions with coffee consumption, compared with abstaining from caffeine.
In patients with type 2 diabetes, a study performed in Japan showed that coffee consumption was associated with reduced all-cause mortality. The results suggested a dose-response relationship, and drinking coffee and green tea appeared to reduce mortality risk further. The results were not generalizable, however, because of the study population’s ethnic homogeneity.
Dose and Toxicity
Caffeine at high doses (> 400 mg daily) and in susceptible patients can induce anxiety, but the effects of caffeine on sleep and anxiety can differ from patient to patient. This variation reflects differences in caffeine metabolism rate and adenosine receptor gene variants.
High caffeine intake can stimulate diuresis, but without causing damaging effects on hydration when taking moderate doses of caffeine (≤ 400 mg daily) for long periods. Stopping caffeine suddenly, in a regular consumer, can lead to withdrawal symptoms such as headache, asthenia, decreased attention, depressed mood, and flu-like symptoms.
The toxic effects of caffeine occur with intake > 1.2 g. A dose of 10-14 g is considered fatal. Caffeine overdose is rare when considering traditional methods of intake (coffee and tea) because 70-100 cups of coffee should be sufficient for caffeine poisoning. Severe events can occur following the use of caffeine tablets or as energy drinks for the following reasons:
- The episodic consumption of caffeine does not allow for tolerance to develop.
- Young people are more vulnerable to the effects of caffeine.
- Caffeine has a synergistic effect in combination with other components in energy drinks.
- Taking caffeine in combination with alcohol or intense exertion causes serious, even fatal, outcomes.
Products Containing Caffeine
Evidence supports the relationship between high consumption (approximately 1 L) of energy drinks with a caffeine content of 320 mg and short-term cardiovascular adverse events, such as increased BP, QT-segment prolongation corrected for heart rate, and palpitations. These tests prompt the recommendation to avoid consuming these beverages in high quantities and in association with alcohol.
Weight loss products generally contain caffeine coupled with herbal extracts that are expected to improve fat metabolism, lipolysis, and oxidation. These products, because of their easy availability, presumed benefits, and high caffeine concentration, may be more susceptible to misuse because they can be taken in larger portions than recommended. The combination of multiple ingredients, concentrated amounts of caffeine, and excessive consumption increases the likelihood of adverse effects.
This story was translated from Univadis Italy, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
New Scanner Creates Highly Detailed, 3D Images of Blood Vessels in Seconds
A new scanner can provide three-dimensional (3D) photoacoustic images of millimeter-scale veins and arteries in seconds.
The scanner, developed by researchers at University College London (UCL) in England, could help clinicians better visualize and track microvascular changes for a wide range of diseases, including cancer, rheumatoid arthritis (RA), and peripheral vascular disease (PVD).
The case studies “illustrate potential areas of application that warrant future, more comprehensive clinical studies,” the authors wrote. “Moreover, they demonstrate the feasibility of using the scanner on a real-world patient cohort where imaging is more challenging due to frailty, comorbidity, or pain that may limit their ability to tolerate prolonged scan times.”
The work was published online in Nature Biomedical Engineering.
Improving Photoacoustic Imaging
PAT works using the photoacoustic effect, a phenomenon where sound waves are generated when light is absorbed by a material. When pulsed light from a laser is directed at tissue, some of that light is absorbed and causes an increase in heat in the targeted area. This localized heat also increases pressure, which generates ultrasound waves that can be detected by specialized sensors.
While previous PAT scanners translated these sound waves to electric signals directly to generate imaging, UCL engineers developed a sensor in the early 2000s that can detect these ultrasound waves using light. The result was much clearer, 3D images.
“That was great, but the problem was it was very slow, and it would take 5 minutes to get an image,” explained Paul Beard, PhD, professor of biomedical photoacoustics at UCL and senior author of the study. “That’s fine if you’re imaging a dead mouse or an anesthetized mouse, but not so useful for human imaging,” he continued, where motion would blur the image.
In this new paper, Beard and colleagues outlined how they cut scanning times to an order of seconds (or fraction of a second) rather than minutes. While previous iterations could detect only acoustic waves from one point at a time, this new scanner can detect waves from multiple points simultaneously. The scanner can visualize veins and arteries up to 15 mm deep in human tissue and can also provide dynamic, 3D images of “time-varying tissue perfusion and other hemodynamic events,” the authors wrote.
With these types of scanners, there is always a trade-off between imaging quality and imaging speed, explained Srivalleesha Mallidi, PhD, an assistant professor of biomedical engineering at Tufts University in Medford, Massachusetts. She was not involved with the work.
“With the resolution that [the authors] are providing and the depth at which they are seeing the signals, it is one of the fastest systems,” she said.
Clinical Utility
Beard and colleagues also tested the scanner to visualize blood vessels in participants with RA, suspected PVD, and skin inflammation. The scanning images “illustrated how vascular abnormalities such as increased vessel tortuosity, which has previously been linked to PVD, and the neovascularization associated with inflammation can be visualized and quantified,” the authors wrote.
The next step, Beard noted, is testing whether these characteristics can be used as a marker for the progression of disease.
Nehal Mehta, MD, a cardiologist and professor of medicine at the George Washington University, Washington, DC, agreed that more longitudinal research is needed to understand how the abnormalities captured in these images can inform detection and diagnosis of various diseases.
“You don’t know whether these images look bad because of reverse causation — the disease is doing this — or true causation — that this is actually detecting the root cause of the disease,” he explained. “Until we have a bank of normal and abnormal scans, we don’t know what any of these things mean.”
Though still some time away from entering the clinic, Mehta likened the technology to the introduction of optical coherence tomography in the 1980s. Before being adapted for clinical use, researchers first needed to visualize differences between normal coronary vasculature and myocardial infarction.
“I think this is an amazingly strong first proof of concept,” Mehta said. “This technology is showing a true promise in the field imaging.”
The work was funded by grants from Cancer Research UK, the Engineering & Physical Sciences Research Council, Wellcome Trust, the European Research Council, and the National Institute for Health and Care Research University College London Hospitals Biomedical Research Centre. Beard and two coauthors are shareholders of DeepColor Imaging to which the intellectual property associated with the new scanner has been licensed, but the company was not involved in any of this research. Mallidi and Mehta had no relevant disclosures.
A version of this article first appeared on Medscape.com.
A new scanner can provide three-dimensional (3D) photoacoustic images of millimeter-scale veins and arteries in seconds.
The scanner, developed by researchers at University College London (UCL) in England, could help clinicians better visualize and track microvascular changes for a wide range of diseases, including cancer, rheumatoid arthritis (RA), and peripheral vascular disease (PVD).
The case studies “illustrate potential areas of application that warrant future, more comprehensive clinical studies,” the authors wrote. “Moreover, they demonstrate the feasibility of using the scanner on a real-world patient cohort where imaging is more challenging due to frailty, comorbidity, or pain that may limit their ability to tolerate prolonged scan times.”
The work was published online in Nature Biomedical Engineering.
Improving Photoacoustic Imaging
PAT works using the photoacoustic effect, a phenomenon where sound waves are generated when light is absorbed by a material. When pulsed light from a laser is directed at tissue, some of that light is absorbed and causes an increase in heat in the targeted area. This localized heat also increases pressure, which generates ultrasound waves that can be detected by specialized sensors.
While previous PAT scanners translated these sound waves to electric signals directly to generate imaging, UCL engineers developed a sensor in the early 2000s that can detect these ultrasound waves using light. The result was much clearer, 3D images.
“That was great, but the problem was it was very slow, and it would take 5 minutes to get an image,” explained Paul Beard, PhD, professor of biomedical photoacoustics at UCL and senior author of the study. “That’s fine if you’re imaging a dead mouse or an anesthetized mouse, but not so useful for human imaging,” he continued, where motion would blur the image.
In this new paper, Beard and colleagues outlined how they cut scanning times to an order of seconds (or fraction of a second) rather than minutes. While previous iterations could detect only acoustic waves from one point at a time, this new scanner can detect waves from multiple points simultaneously. The scanner can visualize veins and arteries up to 15 mm deep in human tissue and can also provide dynamic, 3D images of “time-varying tissue perfusion and other hemodynamic events,” the authors wrote.
With these types of scanners, there is always a trade-off between imaging quality and imaging speed, explained Srivalleesha Mallidi, PhD, an assistant professor of biomedical engineering at Tufts University in Medford, Massachusetts. She was not involved with the work.
“With the resolution that [the authors] are providing and the depth at which they are seeing the signals, it is one of the fastest systems,” she said.
Clinical Utility
Beard and colleagues also tested the scanner to visualize blood vessels in participants with RA, suspected PVD, and skin inflammation. The scanning images “illustrated how vascular abnormalities such as increased vessel tortuosity, which has previously been linked to PVD, and the neovascularization associated with inflammation can be visualized and quantified,” the authors wrote.
The next step, Beard noted, is testing whether these characteristics can be used as a marker for the progression of disease.
Nehal Mehta, MD, a cardiologist and professor of medicine at the George Washington University, Washington, DC, agreed that more longitudinal research is needed to understand how the abnormalities captured in these images can inform detection and diagnosis of various diseases.
“You don’t know whether these images look bad because of reverse causation — the disease is doing this — or true causation — that this is actually detecting the root cause of the disease,” he explained. “Until we have a bank of normal and abnormal scans, we don’t know what any of these things mean.”
Though still some time away from entering the clinic, Mehta likened the technology to the introduction of optical coherence tomography in the 1980s. Before being adapted for clinical use, researchers first needed to visualize differences between normal coronary vasculature and myocardial infarction.
“I think this is an amazingly strong first proof of concept,” Mehta said. “This technology is showing a true promise in the field imaging.”
The work was funded by grants from Cancer Research UK, the Engineering & Physical Sciences Research Council, Wellcome Trust, the European Research Council, and the National Institute for Health and Care Research University College London Hospitals Biomedical Research Centre. Beard and two coauthors are shareholders of DeepColor Imaging to which the intellectual property associated with the new scanner has been licensed, but the company was not involved in any of this research. Mallidi and Mehta had no relevant disclosures.
A version of this article first appeared on Medscape.com.
A new scanner can provide three-dimensional (3D) photoacoustic images of millimeter-scale veins and arteries in seconds.
The scanner, developed by researchers at University College London (UCL) in England, could help clinicians better visualize and track microvascular changes for a wide range of diseases, including cancer, rheumatoid arthritis (RA), and peripheral vascular disease (PVD).
The case studies “illustrate potential areas of application that warrant future, more comprehensive clinical studies,” the authors wrote. “Moreover, they demonstrate the feasibility of using the scanner on a real-world patient cohort where imaging is more challenging due to frailty, comorbidity, or pain that may limit their ability to tolerate prolonged scan times.”
The work was published online in Nature Biomedical Engineering.
Improving Photoacoustic Imaging
PAT works using the photoacoustic effect, a phenomenon where sound waves are generated when light is absorbed by a material. When pulsed light from a laser is directed at tissue, some of that light is absorbed and causes an increase in heat in the targeted area. This localized heat also increases pressure, which generates ultrasound waves that can be detected by specialized sensors.
While previous PAT scanners translated these sound waves to electric signals directly to generate imaging, UCL engineers developed a sensor in the early 2000s that can detect these ultrasound waves using light. The result was much clearer, 3D images.
“That was great, but the problem was it was very slow, and it would take 5 minutes to get an image,” explained Paul Beard, PhD, professor of biomedical photoacoustics at UCL and senior author of the study. “That’s fine if you’re imaging a dead mouse or an anesthetized mouse, but not so useful for human imaging,” he continued, where motion would blur the image.
In this new paper, Beard and colleagues outlined how they cut scanning times to an order of seconds (or fraction of a second) rather than minutes. While previous iterations could detect only acoustic waves from one point at a time, this new scanner can detect waves from multiple points simultaneously. The scanner can visualize veins and arteries up to 15 mm deep in human tissue and can also provide dynamic, 3D images of “time-varying tissue perfusion and other hemodynamic events,” the authors wrote.
With these types of scanners, there is always a trade-off between imaging quality and imaging speed, explained Srivalleesha Mallidi, PhD, an assistant professor of biomedical engineering at Tufts University in Medford, Massachusetts. She was not involved with the work.
“With the resolution that [the authors] are providing and the depth at which they are seeing the signals, it is one of the fastest systems,” she said.
Clinical Utility
Beard and colleagues also tested the scanner to visualize blood vessels in participants with RA, suspected PVD, and skin inflammation. The scanning images “illustrated how vascular abnormalities such as increased vessel tortuosity, which has previously been linked to PVD, and the neovascularization associated with inflammation can be visualized and quantified,” the authors wrote.
The next step, Beard noted, is testing whether these characteristics can be used as a marker for the progression of disease.
Nehal Mehta, MD, a cardiologist and professor of medicine at the George Washington University, Washington, DC, agreed that more longitudinal research is needed to understand how the abnormalities captured in these images can inform detection and diagnosis of various diseases.
“You don’t know whether these images look bad because of reverse causation — the disease is doing this — or true causation — that this is actually detecting the root cause of the disease,” he explained. “Until we have a bank of normal and abnormal scans, we don’t know what any of these things mean.”
Though still some time away from entering the clinic, Mehta likened the technology to the introduction of optical coherence tomography in the 1980s. Before being adapted for clinical use, researchers first needed to visualize differences between normal coronary vasculature and myocardial infarction.
“I think this is an amazingly strong first proof of concept,” Mehta said. “This technology is showing a true promise in the field imaging.”
The work was funded by grants from Cancer Research UK, the Engineering & Physical Sciences Research Council, Wellcome Trust, the European Research Council, and the National Institute for Health and Care Research University College London Hospitals Biomedical Research Centre. Beard and two coauthors are shareholders of DeepColor Imaging to which the intellectual property associated with the new scanner has been licensed, but the company was not involved in any of this research. Mallidi and Mehta had no relevant disclosures.
A version of this article first appeared on Medscape.com.
FROM NATURE BIOMEDICAL ENGINEERING
Maternal Serum Folate Levels During Pregnancy Linked to Congenital Heart Disease Risk
TOPLINE:
Maternal serum folate levels during early to midpregnancy show a U-shaped association with congenital heart disease (CHD) risk in offspring. Both low and high folate levels are linked to an increased risk, with vitamin B12 deficiency and elevated homocysteine levels further exacerbating this risk.
METHODOLOGY:
- Researchers conducted a case-control study with 129 participants with CHD and 516 matched control participants from Guangdong Provincial People’s Hospital in China between 2015 and 2018.
- Maternal serum levels of folate, vitamin B12, and homocysteine were measured at around 16 weeks of gestation using a chemiluminescence microparticle immunoassay.
- CHD was confirmed using echocardiography, and the participants were matched by maternal age at a ratio of 1:4.
- Covariates included periconceptional folic acid supplementation, maternal education, occupation, parity, abortion history, pregnancy complications, and genetic polymorphisms related to folate metabolism.
- Conditional logistic regression was used to assess the associations, with adjustments for various covariates and sensitivity analyses excluding participants with missing genetic data.
TAKEAWAY:
- A U-shaped association was found between maternal serum folate levels and CHD risk in offspring, with both low and high levels linked to increased risk (P < .001).
- Low maternal folate levels were associated with an adjusted odds ratio (aOR) of 3.09 (95% CI, 1.88-5.08) for CHD risk, whereas high levels had an aOR of 1.81 (95% CI, 1.07-3.06).
- Using World Health Organization criteria, folate deficiency (< 5.9 ng/mL) had an aOR of 18.97 (95% CI, 3.87-93.11) and elevated levels (> 20 ng/mL) had an aOR of 5.71 (95% CI, 2.72-11.98) for CHD risk.
- Vitamin B12 deficiency and elevated homocysteine levels further increased the risk associated with both low and high maternal folate levels.
IN PRACTICE:
“Insufficient folate and vitamin B12 can lead to increased homocysteine levels, which is harmful to the cardiovascular system. Thus, homocysteine might act as a central mediator in the relationships between deficiencies in folate and vitamin B12 and the risk of CHD. Additionally, the role of folate extends beyond homocysteine mediation, contributing independently to placental implantation and vascular remodeling, irrespective of vitamin B12 and homocysteine levels,” the authors wrote.
SOURCE:
The study was led by Yanji Qu, PhD, and Jie Li, PhD, Global Health Research Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China. It was published online in JAMA Network Open.
LIMITATIONS:
The study’s limitations included the measurement of maternal serum folate levels at a single time point, which may not reflect preconception and early postconception periods. The study’s findings may not be generalizable to other populations as participants were recruited from a single cardiac referral center in Southern China. Additionally, the lack of dietary intake data limited the ability to account for related biases. The sample size, while relatively large for CHD research, may lack sufficient power for stratified analyses.
DISCLOSURES:
One coauthor reported receiving personal fees from Guangdong Cardiovascular Institute outside the submitted work. Additional disclosures are noted in the original article.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
Maternal serum folate levels during early to midpregnancy show a U-shaped association with congenital heart disease (CHD) risk in offspring. Both low and high folate levels are linked to an increased risk, with vitamin B12 deficiency and elevated homocysteine levels further exacerbating this risk.
METHODOLOGY:
- Researchers conducted a case-control study with 129 participants with CHD and 516 matched control participants from Guangdong Provincial People’s Hospital in China between 2015 and 2018.
- Maternal serum levels of folate, vitamin B12, and homocysteine were measured at around 16 weeks of gestation using a chemiluminescence microparticle immunoassay.
- CHD was confirmed using echocardiography, and the participants were matched by maternal age at a ratio of 1:4.
- Covariates included periconceptional folic acid supplementation, maternal education, occupation, parity, abortion history, pregnancy complications, and genetic polymorphisms related to folate metabolism.
- Conditional logistic regression was used to assess the associations, with adjustments for various covariates and sensitivity analyses excluding participants with missing genetic data.
TAKEAWAY:
- A U-shaped association was found between maternal serum folate levels and CHD risk in offspring, with both low and high levels linked to increased risk (P < .001).
- Low maternal folate levels were associated with an adjusted odds ratio (aOR) of 3.09 (95% CI, 1.88-5.08) for CHD risk, whereas high levels had an aOR of 1.81 (95% CI, 1.07-3.06).
- Using World Health Organization criteria, folate deficiency (< 5.9 ng/mL) had an aOR of 18.97 (95% CI, 3.87-93.11) and elevated levels (> 20 ng/mL) had an aOR of 5.71 (95% CI, 2.72-11.98) for CHD risk.
- Vitamin B12 deficiency and elevated homocysteine levels further increased the risk associated with both low and high maternal folate levels.
IN PRACTICE:
“Insufficient folate and vitamin B12 can lead to increased homocysteine levels, which is harmful to the cardiovascular system. Thus, homocysteine might act as a central mediator in the relationships between deficiencies in folate and vitamin B12 and the risk of CHD. Additionally, the role of folate extends beyond homocysteine mediation, contributing independently to placental implantation and vascular remodeling, irrespective of vitamin B12 and homocysteine levels,” the authors wrote.
SOURCE:
The study was led by Yanji Qu, PhD, and Jie Li, PhD, Global Health Research Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China. It was published online in JAMA Network Open.
LIMITATIONS:
The study’s limitations included the measurement of maternal serum folate levels at a single time point, which may not reflect preconception and early postconception periods. The study’s findings may not be generalizable to other populations as participants were recruited from a single cardiac referral center in Southern China. Additionally, the lack of dietary intake data limited the ability to account for related biases. The sample size, while relatively large for CHD research, may lack sufficient power for stratified analyses.
DISCLOSURES:
One coauthor reported receiving personal fees from Guangdong Cardiovascular Institute outside the submitted work. Additional disclosures are noted in the original article.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
Maternal serum folate levels during early to midpregnancy show a U-shaped association with congenital heart disease (CHD) risk in offspring. Both low and high folate levels are linked to an increased risk, with vitamin B12 deficiency and elevated homocysteine levels further exacerbating this risk.
METHODOLOGY:
- Researchers conducted a case-control study with 129 participants with CHD and 516 matched control participants from Guangdong Provincial People’s Hospital in China between 2015 and 2018.
- Maternal serum levels of folate, vitamin B12, and homocysteine were measured at around 16 weeks of gestation using a chemiluminescence microparticle immunoassay.
- CHD was confirmed using echocardiography, and the participants were matched by maternal age at a ratio of 1:4.
- Covariates included periconceptional folic acid supplementation, maternal education, occupation, parity, abortion history, pregnancy complications, and genetic polymorphisms related to folate metabolism.
- Conditional logistic regression was used to assess the associations, with adjustments for various covariates and sensitivity analyses excluding participants with missing genetic data.
TAKEAWAY:
- A U-shaped association was found between maternal serum folate levels and CHD risk in offspring, with both low and high levels linked to increased risk (P < .001).
- Low maternal folate levels were associated with an adjusted odds ratio (aOR) of 3.09 (95% CI, 1.88-5.08) for CHD risk, whereas high levels had an aOR of 1.81 (95% CI, 1.07-3.06).
- Using World Health Organization criteria, folate deficiency (< 5.9 ng/mL) had an aOR of 18.97 (95% CI, 3.87-93.11) and elevated levels (> 20 ng/mL) had an aOR of 5.71 (95% CI, 2.72-11.98) for CHD risk.
- Vitamin B12 deficiency and elevated homocysteine levels further increased the risk associated with both low and high maternal folate levels.
IN PRACTICE:
“Insufficient folate and vitamin B12 can lead to increased homocysteine levels, which is harmful to the cardiovascular system. Thus, homocysteine might act as a central mediator in the relationships between deficiencies in folate and vitamin B12 and the risk of CHD. Additionally, the role of folate extends beyond homocysteine mediation, contributing independently to placental implantation and vascular remodeling, irrespective of vitamin B12 and homocysteine levels,” the authors wrote.
SOURCE:
The study was led by Yanji Qu, PhD, and Jie Li, PhD, Global Health Research Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China. It was published online in JAMA Network Open.
LIMITATIONS:
The study’s limitations included the measurement of maternal serum folate levels at a single time point, which may not reflect preconception and early postconception periods. The study’s findings may not be generalizable to other populations as participants were recruited from a single cardiac referral center in Southern China. Additionally, the lack of dietary intake data limited the ability to account for related biases. The sample size, while relatively large for CHD research, may lack sufficient power for stratified analyses.
DISCLOSURES:
One coauthor reported receiving personal fees from Guangdong Cardiovascular Institute outside the submitted work. Additional disclosures are noted in the original article.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
New Evidence That Plaque Buildup Shouldn’t Be Ignored
Subclinical disease detected on imaging predicts death, report investigators who show that plaque burden found on 3D vascular ultrasound and coronary artery calcium on CT were better predictors of death than traditional risk factors.
The work not only highlights the importance of early detection, but it also has clinical implications, said Valentin Fuster, MD, president of the Mount Sinai Fuster Heart Hospital in New York. “It’s going to change things,” he said. “What I believe is going to happen is that we will begin to evaluate people with risk factors at age 30 using imaging. Today, we evaluate people at age 50 using clinical practice guidelines.”
Fuster’s team developed 3D vascular ultrasound to assess plaque burden and applied it in a prospective cohort study known as BioImage. The researchers assessed 6102 patients in Chicago, Illinois, and Fort Lauderdale, Florida, using 3D vascular ultrasound of the carotid artery and another well-established modality — coronary artery calcium, determined by CT.
Participants had no cardiovascular symptoms, yet their plaque burden and calcium scores at the beginning of the study were significantly associated with death during the 15 years of follow-up, even after taking risk factors and medication into account. The results are published in the Journal of the American College of Cardiology.
“Now, there is no question that subclinical disease on imaging predicts mortality,” said Fuster.
David J. Maron, MD, a preventive cardiologist at the Stanford University School of Medicine in California, calls the finding “very important.”
“The presence of atherosclerosis is powerful knowledge to guide the intensity of therapy and to motivate patients and clinicians to treat it,” said Maron, who is the co-author of an accompanying editorial and was not involved in the study.
Predicting Risk Early
The research also showed that the risk for death increases if the burden of plaque in the carotid artery increases over time. Both plaque burden shown on 3D vascular ultrasound and coronary artery calcium on CT were better predictors of death than traditional risk factors.
Maron says recent studies of younger populations, such as Progression of Early Subclinical Atherosclerosis (PESA) and Coronary Artery Risk Development in Young Adults (CARDIA), show that “risk factors at a young age have much more impact on arterial disease than when we measure risk factors at older age.” The CARDIA study showed signs of atherosclerosis in patients as young as in their twenties. This paradigm shift to early detection will now be possible thanks to technological advances like 3D vascular ultrasound.
Maron said he agrees with screening earlier in life. “The risk of having an event is related to the plaque burden and the number of years that a patient has been exposed to that burden. The earlier in life we can identify the burden to slow, arrest, or even reverse the plaque, the better.”
Maron points out that the study looked at an older population and did not include information on cause of death. While a study of younger people and data on cardiac causes of death would be useful, he says the study’s conclusions remain significant.
3D Vascular Ultrasound vs Coronary Artery Calcium
While both imaging methods in the study predicted death better than cardiovascular risk factors alone, each option has advantages.
For coronary artery calcium, “there’s a huge amount of literature demonstrating the association with cardiovascular events, there’s a standardized scoring system, there are widespread facilities for computed tomography, and there is not a lot of variability in the measurement — it’s not dependent on the operator,” said Maron.
But there is one drawback. The scoring system –— the Agatston score — can paradoxically go up following aggressive lowering of low-density lipoprotein cholesterol. “Once coronary calcium is present, it is challenging to interpret a repeat scan because we don’t know if the increase in score is due to progression or increasing density of the calcium, which is a sign of healing,” said Maron.
Vascular ultrasound avoids this problem and can also identify early noncalcified plaques and monitor their progression before they would appear on CT. Furthermore, the imaging does not add to lifetime radiation dose, as CT does, Fuster said.
3D ultrasound technology will soon be available in an inexpensive, automated, and easy-to-use format, he explains. Fuster envisions a scenario in which a nurse in a low-income country, using a cell phone app, will be able to assess atherosclerosis in a patient’s femoral artery. “In less than 1 hour, we can predict disease much more rigorously than with risk factors alone,” he said. “I think this is very exciting.”
Progression Increases Risk
Finding any atherosclerosis means an increased risk for death, but a greater burden or amount of atherosclerosis increases that risk, said Fuster. Progression of atherosclerosis increases risk even further.
The study looked at changes in atherosclerosis burden on vascular ultrasound in a subset of 732 patients a median of 8.9 years after their first test. Those with progression had a higher risk for death than those with regression or no atherosclerosis. “Progression is much more significant in predicting mortality than atherosclerosis findings alone,” Fuster said.
Maron said this finding points to “two great values from noninvasive imaging of atherosclerosis.” Not only does imaging detect atherosclerosis, but it can also characterize the burden and any calcification. Further, it allows doctors to monitor the response to interventions such as lifestyle changes and medical therapy. “Serial imaging of plaque burden will really enhance the management of atherosclerosis,” said Maron. “If we discover that someone is progressing rapidly, we can intensify therapy.”
He says imaging results also provide needed motivation for both clinicians and patients to take action that would prevent the deaths that result from atherosclerosis.
A version of this article appeared on Medscape.com.
Subclinical disease detected on imaging predicts death, report investigators who show that plaque burden found on 3D vascular ultrasound and coronary artery calcium on CT were better predictors of death than traditional risk factors.
The work not only highlights the importance of early detection, but it also has clinical implications, said Valentin Fuster, MD, president of the Mount Sinai Fuster Heart Hospital in New York. “It’s going to change things,” he said. “What I believe is going to happen is that we will begin to evaluate people with risk factors at age 30 using imaging. Today, we evaluate people at age 50 using clinical practice guidelines.”
Fuster’s team developed 3D vascular ultrasound to assess plaque burden and applied it in a prospective cohort study known as BioImage. The researchers assessed 6102 patients in Chicago, Illinois, and Fort Lauderdale, Florida, using 3D vascular ultrasound of the carotid artery and another well-established modality — coronary artery calcium, determined by CT.
Participants had no cardiovascular symptoms, yet their plaque burden and calcium scores at the beginning of the study were significantly associated with death during the 15 years of follow-up, even after taking risk factors and medication into account. The results are published in the Journal of the American College of Cardiology.
“Now, there is no question that subclinical disease on imaging predicts mortality,” said Fuster.
David J. Maron, MD, a preventive cardiologist at the Stanford University School of Medicine in California, calls the finding “very important.”
“The presence of atherosclerosis is powerful knowledge to guide the intensity of therapy and to motivate patients and clinicians to treat it,” said Maron, who is the co-author of an accompanying editorial and was not involved in the study.
Predicting Risk Early
The research also showed that the risk for death increases if the burden of plaque in the carotid artery increases over time. Both plaque burden shown on 3D vascular ultrasound and coronary artery calcium on CT were better predictors of death than traditional risk factors.
Maron says recent studies of younger populations, such as Progression of Early Subclinical Atherosclerosis (PESA) and Coronary Artery Risk Development in Young Adults (CARDIA), show that “risk factors at a young age have much more impact on arterial disease than when we measure risk factors at older age.” The CARDIA study showed signs of atherosclerosis in patients as young as in their twenties. This paradigm shift to early detection will now be possible thanks to technological advances like 3D vascular ultrasound.
Maron said he agrees with screening earlier in life. “The risk of having an event is related to the plaque burden and the number of years that a patient has been exposed to that burden. The earlier in life we can identify the burden to slow, arrest, or even reverse the plaque, the better.”
Maron points out that the study looked at an older population and did not include information on cause of death. While a study of younger people and data on cardiac causes of death would be useful, he says the study’s conclusions remain significant.
3D Vascular Ultrasound vs Coronary Artery Calcium
While both imaging methods in the study predicted death better than cardiovascular risk factors alone, each option has advantages.
For coronary artery calcium, “there’s a huge amount of literature demonstrating the association with cardiovascular events, there’s a standardized scoring system, there are widespread facilities for computed tomography, and there is not a lot of variability in the measurement — it’s not dependent on the operator,” said Maron.
But there is one drawback. The scoring system –— the Agatston score — can paradoxically go up following aggressive lowering of low-density lipoprotein cholesterol. “Once coronary calcium is present, it is challenging to interpret a repeat scan because we don’t know if the increase in score is due to progression or increasing density of the calcium, which is a sign of healing,” said Maron.
Vascular ultrasound avoids this problem and can also identify early noncalcified plaques and monitor their progression before they would appear on CT. Furthermore, the imaging does not add to lifetime radiation dose, as CT does, Fuster said.
3D ultrasound technology will soon be available in an inexpensive, automated, and easy-to-use format, he explains. Fuster envisions a scenario in which a nurse in a low-income country, using a cell phone app, will be able to assess atherosclerosis in a patient’s femoral artery. “In less than 1 hour, we can predict disease much more rigorously than with risk factors alone,” he said. “I think this is very exciting.”
Progression Increases Risk
Finding any atherosclerosis means an increased risk for death, but a greater burden or amount of atherosclerosis increases that risk, said Fuster. Progression of atherosclerosis increases risk even further.
The study looked at changes in atherosclerosis burden on vascular ultrasound in a subset of 732 patients a median of 8.9 years after their first test. Those with progression had a higher risk for death than those with regression or no atherosclerosis. “Progression is much more significant in predicting mortality than atherosclerosis findings alone,” Fuster said.
Maron said this finding points to “two great values from noninvasive imaging of atherosclerosis.” Not only does imaging detect atherosclerosis, but it can also characterize the burden and any calcification. Further, it allows doctors to monitor the response to interventions such as lifestyle changes and medical therapy. “Serial imaging of plaque burden will really enhance the management of atherosclerosis,” said Maron. “If we discover that someone is progressing rapidly, we can intensify therapy.”
He says imaging results also provide needed motivation for both clinicians and patients to take action that would prevent the deaths that result from atherosclerosis.
A version of this article appeared on Medscape.com.
Subclinical disease detected on imaging predicts death, report investigators who show that plaque burden found on 3D vascular ultrasound and coronary artery calcium on CT were better predictors of death than traditional risk factors.
The work not only highlights the importance of early detection, but it also has clinical implications, said Valentin Fuster, MD, president of the Mount Sinai Fuster Heart Hospital in New York. “It’s going to change things,” he said. “What I believe is going to happen is that we will begin to evaluate people with risk factors at age 30 using imaging. Today, we evaluate people at age 50 using clinical practice guidelines.”
Fuster’s team developed 3D vascular ultrasound to assess plaque burden and applied it in a prospective cohort study known as BioImage. The researchers assessed 6102 patients in Chicago, Illinois, and Fort Lauderdale, Florida, using 3D vascular ultrasound of the carotid artery and another well-established modality — coronary artery calcium, determined by CT.
Participants had no cardiovascular symptoms, yet their plaque burden and calcium scores at the beginning of the study were significantly associated with death during the 15 years of follow-up, even after taking risk factors and medication into account. The results are published in the Journal of the American College of Cardiology.
“Now, there is no question that subclinical disease on imaging predicts mortality,” said Fuster.
David J. Maron, MD, a preventive cardiologist at the Stanford University School of Medicine in California, calls the finding “very important.”
“The presence of atherosclerosis is powerful knowledge to guide the intensity of therapy and to motivate patients and clinicians to treat it,” said Maron, who is the co-author of an accompanying editorial and was not involved in the study.
Predicting Risk Early
The research also showed that the risk for death increases if the burden of plaque in the carotid artery increases over time. Both plaque burden shown on 3D vascular ultrasound and coronary artery calcium on CT were better predictors of death than traditional risk factors.
Maron says recent studies of younger populations, such as Progression of Early Subclinical Atherosclerosis (PESA) and Coronary Artery Risk Development in Young Adults (CARDIA), show that “risk factors at a young age have much more impact on arterial disease than when we measure risk factors at older age.” The CARDIA study showed signs of atherosclerosis in patients as young as in their twenties. This paradigm shift to early detection will now be possible thanks to technological advances like 3D vascular ultrasound.
Maron said he agrees with screening earlier in life. “The risk of having an event is related to the plaque burden and the number of years that a patient has been exposed to that burden. The earlier in life we can identify the burden to slow, arrest, or even reverse the plaque, the better.”
Maron points out that the study looked at an older population and did not include information on cause of death. While a study of younger people and data on cardiac causes of death would be useful, he says the study’s conclusions remain significant.
3D Vascular Ultrasound vs Coronary Artery Calcium
While both imaging methods in the study predicted death better than cardiovascular risk factors alone, each option has advantages.
For coronary artery calcium, “there’s a huge amount of literature demonstrating the association with cardiovascular events, there’s a standardized scoring system, there are widespread facilities for computed tomography, and there is not a lot of variability in the measurement — it’s not dependent on the operator,” said Maron.
But there is one drawback. The scoring system –— the Agatston score — can paradoxically go up following aggressive lowering of low-density lipoprotein cholesterol. “Once coronary calcium is present, it is challenging to interpret a repeat scan because we don’t know if the increase in score is due to progression or increasing density of the calcium, which is a sign of healing,” said Maron.
Vascular ultrasound avoids this problem and can also identify early noncalcified plaques and monitor their progression before they would appear on CT. Furthermore, the imaging does not add to lifetime radiation dose, as CT does, Fuster said.
3D ultrasound technology will soon be available in an inexpensive, automated, and easy-to-use format, he explains. Fuster envisions a scenario in which a nurse in a low-income country, using a cell phone app, will be able to assess atherosclerosis in a patient’s femoral artery. “In less than 1 hour, we can predict disease much more rigorously than with risk factors alone,” he said. “I think this is very exciting.”
Progression Increases Risk
Finding any atherosclerosis means an increased risk for death, but a greater burden or amount of atherosclerosis increases that risk, said Fuster. Progression of atherosclerosis increases risk even further.
The study looked at changes in atherosclerosis burden on vascular ultrasound in a subset of 732 patients a median of 8.9 years after their first test. Those with progression had a higher risk for death than those with regression or no atherosclerosis. “Progression is much more significant in predicting mortality than atherosclerosis findings alone,” Fuster said.
Maron said this finding points to “two great values from noninvasive imaging of atherosclerosis.” Not only does imaging detect atherosclerosis, but it can also characterize the burden and any calcification. Further, it allows doctors to monitor the response to interventions such as lifestyle changes and medical therapy. “Serial imaging of plaque burden will really enhance the management of atherosclerosis,” said Maron. “If we discover that someone is progressing rapidly, we can intensify therapy.”
He says imaging results also provide needed motivation for both clinicians and patients to take action that would prevent the deaths that result from atherosclerosis.
A version of this article appeared on Medscape.com.
Trend Toward Higher Mortality in Patients With CF and CVD
BOSTON — With the remarkable advances made in therapy over the past decade, many patients with cystic fibrosis (CF) can expect to survive into their 50s and even well beyond. And as evidence from a new study suggests, there is an increasing need for cardiovascular screening and specialized cardiac care for these patients.
Among more than 83,000 patients with CF hospitalized for any reason from 2016 through 2021, less than 1% of patients had a cardiac cause listed, but in unadjusted analyses, these patients had a more than twofold risk for in-hospital death than those with CF hospitalized for other causes, reported Adnan Bhat, MD, assistant professor of hospital medicine at the University of Florida, Gainesville.
Although the excess mortality was no longer statistically significant in analyses adjusted for potential confounding factors, the data highlight a trend that requires further exploration, he said during an oral abstract session at the annual meeting of the American College of Chest Physicians (CHEST).
“There’s a trend for people with cystic fibrosis admitted for cardiac causes to have a higher in-hospital mortality and increased rate of discharge to nursing facilities, especially for patients admitted for heart failure. The clinical implication is that there is an increased need to start screening for cardiovascular risk factors,” he said.
National Database Sample
Bhat and colleagues conducted a retrospective study using the National Inpatient Sample database to identify all hospitalizations among patients with CF in the United States from 2016 through 2021.
They included all hospitalizations with a principal diagnosis code for atrial fibrillation, heart failure, or myocardial infarction.
Of 83,250 total hospitalizations during the study period, 415 (0.5%) were for primary cardiac causes. These included 170 hospitalizations for atrial fibrillation, 95 for heart failure, and 150 for myocardial infarction.
Patients hospitalized for cardiac causes had a higher mean age (59.5 vs 34.5 years) and more comorbidities than patients hospitalized for other causes. These comorbidities included hyperlipidemia, chronic kidney disease, obesity, and a family history of coronary artery disease.
In all, 5% of patients hospitalized for cardiac cause died in hospital, compared with 2% of patients hospitalized for other reasons (P = .044).
However, in logistic regression analyses adjusting for age, sex, and race, this difference was no longer significant.
Similarly, an unadjusted analysis showed that patients with cardiac disease were twice as likely to be discharged to a nursing facility (8% vs 4%, respectively), but this difference too disappeared in adjusted analyses.
The risk for in-hospital mortality appeared to be highest among those patients with a primary diagnosis of heart failure, who had an 11% rate of in-hospital death, compared with 2% among patients with CF hospitalized for other causes.
The total number of deaths was too small, however, to allow for regression analysis, Bhat said.
Nonetheless, taken together, the data indicate a trend toward increased mortality from cardiovascular causes among older patients with CF, as well as the need for further research into the cardiovascular health of these patients, Bhat concluded.
Better Nutrition, Higher Risk
In an interview, Yuqing A. Gao, MD, from the Santa Monica Pulmonary Sleep Clinic in California, who was not involved in the study, commented that with the advent of elexacaftor/tezacaftor/ivacaftor modulator therapy, patients with CF tend to have increases in body mass index and improved nutritional intake and absorption, which in turn could increase hyperlipidemia and other factors that might in turn contribute to increased CVD risk.
“It’s really an interesting area of research, and there’s hope that this will bring more focus on how to better screen [for CVD risk] because that’s something that’s very much not known at this time,” she said.
Gao was co-moderator for the session where Bhat presented the data. Bhat did not report a study funding source. Bhat and Gao reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
BOSTON — With the remarkable advances made in therapy over the past decade, many patients with cystic fibrosis (CF) can expect to survive into their 50s and even well beyond. And as evidence from a new study suggests, there is an increasing need for cardiovascular screening and specialized cardiac care for these patients.
Among more than 83,000 patients with CF hospitalized for any reason from 2016 through 2021, less than 1% of patients had a cardiac cause listed, but in unadjusted analyses, these patients had a more than twofold risk for in-hospital death than those with CF hospitalized for other causes, reported Adnan Bhat, MD, assistant professor of hospital medicine at the University of Florida, Gainesville.
Although the excess mortality was no longer statistically significant in analyses adjusted for potential confounding factors, the data highlight a trend that requires further exploration, he said during an oral abstract session at the annual meeting of the American College of Chest Physicians (CHEST).
“There’s a trend for people with cystic fibrosis admitted for cardiac causes to have a higher in-hospital mortality and increased rate of discharge to nursing facilities, especially for patients admitted for heart failure. The clinical implication is that there is an increased need to start screening for cardiovascular risk factors,” he said.
National Database Sample
Bhat and colleagues conducted a retrospective study using the National Inpatient Sample database to identify all hospitalizations among patients with CF in the United States from 2016 through 2021.
They included all hospitalizations with a principal diagnosis code for atrial fibrillation, heart failure, or myocardial infarction.
Of 83,250 total hospitalizations during the study period, 415 (0.5%) were for primary cardiac causes. These included 170 hospitalizations for atrial fibrillation, 95 for heart failure, and 150 for myocardial infarction.
Patients hospitalized for cardiac causes had a higher mean age (59.5 vs 34.5 years) and more comorbidities than patients hospitalized for other causes. These comorbidities included hyperlipidemia, chronic kidney disease, obesity, and a family history of coronary artery disease.
In all, 5% of patients hospitalized for cardiac cause died in hospital, compared with 2% of patients hospitalized for other reasons (P = .044).
However, in logistic regression analyses adjusting for age, sex, and race, this difference was no longer significant.
Similarly, an unadjusted analysis showed that patients with cardiac disease were twice as likely to be discharged to a nursing facility (8% vs 4%, respectively), but this difference too disappeared in adjusted analyses.
The risk for in-hospital mortality appeared to be highest among those patients with a primary diagnosis of heart failure, who had an 11% rate of in-hospital death, compared with 2% among patients with CF hospitalized for other causes.
The total number of deaths was too small, however, to allow for regression analysis, Bhat said.
Nonetheless, taken together, the data indicate a trend toward increased mortality from cardiovascular causes among older patients with CF, as well as the need for further research into the cardiovascular health of these patients, Bhat concluded.
Better Nutrition, Higher Risk
In an interview, Yuqing A. Gao, MD, from the Santa Monica Pulmonary Sleep Clinic in California, who was not involved in the study, commented that with the advent of elexacaftor/tezacaftor/ivacaftor modulator therapy, patients with CF tend to have increases in body mass index and improved nutritional intake and absorption, which in turn could increase hyperlipidemia and other factors that might in turn contribute to increased CVD risk.
“It’s really an interesting area of research, and there’s hope that this will bring more focus on how to better screen [for CVD risk] because that’s something that’s very much not known at this time,” she said.
Gao was co-moderator for the session where Bhat presented the data. Bhat did not report a study funding source. Bhat and Gao reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
BOSTON — With the remarkable advances made in therapy over the past decade, many patients with cystic fibrosis (CF) can expect to survive into their 50s and even well beyond. And as evidence from a new study suggests, there is an increasing need for cardiovascular screening and specialized cardiac care for these patients.
Among more than 83,000 patients with CF hospitalized for any reason from 2016 through 2021, less than 1% of patients had a cardiac cause listed, but in unadjusted analyses, these patients had a more than twofold risk for in-hospital death than those with CF hospitalized for other causes, reported Adnan Bhat, MD, assistant professor of hospital medicine at the University of Florida, Gainesville.
Although the excess mortality was no longer statistically significant in analyses adjusted for potential confounding factors, the data highlight a trend that requires further exploration, he said during an oral abstract session at the annual meeting of the American College of Chest Physicians (CHEST).
“There’s a trend for people with cystic fibrosis admitted for cardiac causes to have a higher in-hospital mortality and increased rate of discharge to nursing facilities, especially for patients admitted for heart failure. The clinical implication is that there is an increased need to start screening for cardiovascular risk factors,” he said.
National Database Sample
Bhat and colleagues conducted a retrospective study using the National Inpatient Sample database to identify all hospitalizations among patients with CF in the United States from 2016 through 2021.
They included all hospitalizations with a principal diagnosis code for atrial fibrillation, heart failure, or myocardial infarction.
Of 83,250 total hospitalizations during the study period, 415 (0.5%) were for primary cardiac causes. These included 170 hospitalizations for atrial fibrillation, 95 for heart failure, and 150 for myocardial infarction.
Patients hospitalized for cardiac causes had a higher mean age (59.5 vs 34.5 years) and more comorbidities than patients hospitalized for other causes. These comorbidities included hyperlipidemia, chronic kidney disease, obesity, and a family history of coronary artery disease.
In all, 5% of patients hospitalized for cardiac cause died in hospital, compared with 2% of patients hospitalized for other reasons (P = .044).
However, in logistic regression analyses adjusting for age, sex, and race, this difference was no longer significant.
Similarly, an unadjusted analysis showed that patients with cardiac disease were twice as likely to be discharged to a nursing facility (8% vs 4%, respectively), but this difference too disappeared in adjusted analyses.
The risk for in-hospital mortality appeared to be highest among those patients with a primary diagnosis of heart failure, who had an 11% rate of in-hospital death, compared with 2% among patients with CF hospitalized for other causes.
The total number of deaths was too small, however, to allow for regression analysis, Bhat said.
Nonetheless, taken together, the data indicate a trend toward increased mortality from cardiovascular causes among older patients with CF, as well as the need for further research into the cardiovascular health of these patients, Bhat concluded.
Better Nutrition, Higher Risk
In an interview, Yuqing A. Gao, MD, from the Santa Monica Pulmonary Sleep Clinic in California, who was not involved in the study, commented that with the advent of elexacaftor/tezacaftor/ivacaftor modulator therapy, patients with CF tend to have increases in body mass index and improved nutritional intake and absorption, which in turn could increase hyperlipidemia and other factors that might in turn contribute to increased CVD risk.
“It’s really an interesting area of research, and there’s hope that this will bring more focus on how to better screen [for CVD risk] because that’s something that’s very much not known at this time,” she said.
Gao was co-moderator for the session where Bhat presented the data. Bhat did not report a study funding source. Bhat and Gao reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
FROM CHEST 2024
Use of SGLT2 Inhibitors Associated With Better Survival in PAH
BOSTON — The use of sodium-glucose cotransporter-2 (SGLT2) inhibitors is associated with reduced short- and long-term mortality among patients with pulmonary arterial hypertension (PAH), according to results from a new propensity score–matched analysis.
“There are a lot of new studies that show benefits [of SGLT2 inhibitors] in heart failure, in [chronic kidney disease], and of course, in diabetes. There are studies that show that SGLT2 inhibitors can have an impact on inflammatory cascades, fibrosis, and vascular remodeling in general. Together, all this data triggered this idea for me, and that’s when I decided to conduct further studies,” said Irakli Lemonjava, MD, who presented the study at the American College of Chest Physicians (CHEST) 2024 Annual Meeting.
The researchers drew data on 125,634 adult patients from the TriNetX database who were diagnosed with PAH after January 1, 2013. They used propensity score matching to account for demographic characteristics and 10 organ system disorders to compare patients with exposure to SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, or ertugliflozin; n = 6238) with those without such exposure (n = 6243).
At 1 year, 8.1% of patients taking SGLT2 inhibitors had died, compared with 15.5% of patients not taking SGLT2 inhibitors (risk reduction [RR], 0.52; P < .0001). The values were 13% and 22.5% (RR, 0.579; P < .0001) at 3 years and 14.6% and 25% at 5 years (RR, 0.583; P < .0001).
The study generated discussion during the Q&A period following the talk. One audience member asked if the group was able to access patients both inside and outside the United States. “Because I wonder if access to GLP2 inhibitors is actually a surrogate marker for access to other medications,” the questioner said.
Although the finding is intriguing, it shouldn’t change clinical practice, according to Lemonjava. “I don’t think we can make any changes based on what I shared today. Our purpose was to trigger the question. I think the numbers are so impressive that it will trigger more studies. I think if in the future it’s demonstrated by clinical trials that [SGLT2 inhibitors are beneficial], it will not be a problem to prescribe for someone with pulmonary arterial hypertension because they do not have many side effects,” he said. Lemonjava is a resident physician at Jefferson Einstein Philadelphia Hospital, Philadelphia.
Session co-moderator said Syed Rehan Quadery, MD, praised the study but emphasized the remaining uncertainty. “It’s an excellent proof of concept study. More trials need to [be done] on it, and we don’t understand the mechanism of action in which it improves survival in patients with pulmonary artery hypertension. The majority of the patients with pulmonary hypertension are much older and they have comorbidities, including cardiovascular risk factors, and maybe that is one of the ways in which this drug helps. Plus, there are multiple mechanisms in which it may be working, including anti-inflammatory as well as antiproliferative mechanisms through inhibiting the Notch-3 signaling pathway,” said Quadery, who is a consultant respiratory physician at National Pulmonary Hypertension Unit, Dublin, Ireland.
Quadery and his co-moderator Zeenat Safdar, MD, both noted that SGLT2 inhibitors have already been demonstrated to improve outcomes in heart failure. “[SGLT2 inhibition] improves survival, it decreases hospitalization, it improves morbidity and mortality. There are a lot of things that can be shown in different [animal or in vitro] models. In humans, we actually don’t know exactly how it works, but we know that it does. If it works in left heart failure, it also [could] work in right heart failure,” said Safdar, who is the director of the Houston Methodist Lung Center, Houston Methodist Hospital, Houston.
The study was independently supported. Lemonjava, Quadery, and Safdar reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
BOSTON — The use of sodium-glucose cotransporter-2 (SGLT2) inhibitors is associated with reduced short- and long-term mortality among patients with pulmonary arterial hypertension (PAH), according to results from a new propensity score–matched analysis.
“There are a lot of new studies that show benefits [of SGLT2 inhibitors] in heart failure, in [chronic kidney disease], and of course, in diabetes. There are studies that show that SGLT2 inhibitors can have an impact on inflammatory cascades, fibrosis, and vascular remodeling in general. Together, all this data triggered this idea for me, and that’s when I decided to conduct further studies,” said Irakli Lemonjava, MD, who presented the study at the American College of Chest Physicians (CHEST) 2024 Annual Meeting.
The researchers drew data on 125,634 adult patients from the TriNetX database who were diagnosed with PAH after January 1, 2013. They used propensity score matching to account for demographic characteristics and 10 organ system disorders to compare patients with exposure to SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, or ertugliflozin; n = 6238) with those without such exposure (n = 6243).
At 1 year, 8.1% of patients taking SGLT2 inhibitors had died, compared with 15.5% of patients not taking SGLT2 inhibitors (risk reduction [RR], 0.52; P < .0001). The values were 13% and 22.5% (RR, 0.579; P < .0001) at 3 years and 14.6% and 25% at 5 years (RR, 0.583; P < .0001).
The study generated discussion during the Q&A period following the talk. One audience member asked if the group was able to access patients both inside and outside the United States. “Because I wonder if access to GLP2 inhibitors is actually a surrogate marker for access to other medications,” the questioner said.
Although the finding is intriguing, it shouldn’t change clinical practice, according to Lemonjava. “I don’t think we can make any changes based on what I shared today. Our purpose was to trigger the question. I think the numbers are so impressive that it will trigger more studies. I think if in the future it’s demonstrated by clinical trials that [SGLT2 inhibitors are beneficial], it will not be a problem to prescribe for someone with pulmonary arterial hypertension because they do not have many side effects,” he said. Lemonjava is a resident physician at Jefferson Einstein Philadelphia Hospital, Philadelphia.
Session co-moderator said Syed Rehan Quadery, MD, praised the study but emphasized the remaining uncertainty. “It’s an excellent proof of concept study. More trials need to [be done] on it, and we don’t understand the mechanism of action in which it improves survival in patients with pulmonary artery hypertension. The majority of the patients with pulmonary hypertension are much older and they have comorbidities, including cardiovascular risk factors, and maybe that is one of the ways in which this drug helps. Plus, there are multiple mechanisms in which it may be working, including anti-inflammatory as well as antiproliferative mechanisms through inhibiting the Notch-3 signaling pathway,” said Quadery, who is a consultant respiratory physician at National Pulmonary Hypertension Unit, Dublin, Ireland.
Quadery and his co-moderator Zeenat Safdar, MD, both noted that SGLT2 inhibitors have already been demonstrated to improve outcomes in heart failure. “[SGLT2 inhibition] improves survival, it decreases hospitalization, it improves morbidity and mortality. There are a lot of things that can be shown in different [animal or in vitro] models. In humans, we actually don’t know exactly how it works, but we know that it does. If it works in left heart failure, it also [could] work in right heart failure,” said Safdar, who is the director of the Houston Methodist Lung Center, Houston Methodist Hospital, Houston.
The study was independently supported. Lemonjava, Quadery, and Safdar reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
BOSTON — The use of sodium-glucose cotransporter-2 (SGLT2) inhibitors is associated with reduced short- and long-term mortality among patients with pulmonary arterial hypertension (PAH), according to results from a new propensity score–matched analysis.
“There are a lot of new studies that show benefits [of SGLT2 inhibitors] in heart failure, in [chronic kidney disease], and of course, in diabetes. There are studies that show that SGLT2 inhibitors can have an impact on inflammatory cascades, fibrosis, and vascular remodeling in general. Together, all this data triggered this idea for me, and that’s when I decided to conduct further studies,” said Irakli Lemonjava, MD, who presented the study at the American College of Chest Physicians (CHEST) 2024 Annual Meeting.
The researchers drew data on 125,634 adult patients from the TriNetX database who were diagnosed with PAH after January 1, 2013. They used propensity score matching to account for demographic characteristics and 10 organ system disorders to compare patients with exposure to SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, or ertugliflozin; n = 6238) with those without such exposure (n = 6243).
At 1 year, 8.1% of patients taking SGLT2 inhibitors had died, compared with 15.5% of patients not taking SGLT2 inhibitors (risk reduction [RR], 0.52; P < .0001). The values were 13% and 22.5% (RR, 0.579; P < .0001) at 3 years and 14.6% and 25% at 5 years (RR, 0.583; P < .0001).
The study generated discussion during the Q&A period following the talk. One audience member asked if the group was able to access patients both inside and outside the United States. “Because I wonder if access to GLP2 inhibitors is actually a surrogate marker for access to other medications,” the questioner said.
Although the finding is intriguing, it shouldn’t change clinical practice, according to Lemonjava. “I don’t think we can make any changes based on what I shared today. Our purpose was to trigger the question. I think the numbers are so impressive that it will trigger more studies. I think if in the future it’s demonstrated by clinical trials that [SGLT2 inhibitors are beneficial], it will not be a problem to prescribe for someone with pulmonary arterial hypertension because they do not have many side effects,” he said. Lemonjava is a resident physician at Jefferson Einstein Philadelphia Hospital, Philadelphia.
Session co-moderator said Syed Rehan Quadery, MD, praised the study but emphasized the remaining uncertainty. “It’s an excellent proof of concept study. More trials need to [be done] on it, and we don’t understand the mechanism of action in which it improves survival in patients with pulmonary artery hypertension. The majority of the patients with pulmonary hypertension are much older and they have comorbidities, including cardiovascular risk factors, and maybe that is one of the ways in which this drug helps. Plus, there are multiple mechanisms in which it may be working, including anti-inflammatory as well as antiproliferative mechanisms through inhibiting the Notch-3 signaling pathway,” said Quadery, who is a consultant respiratory physician at National Pulmonary Hypertension Unit, Dublin, Ireland.
Quadery and his co-moderator Zeenat Safdar, MD, both noted that SGLT2 inhibitors have already been demonstrated to improve outcomes in heart failure. “[SGLT2 inhibition] improves survival, it decreases hospitalization, it improves morbidity and mortality. There are a lot of things that can be shown in different [animal or in vitro] models. In humans, we actually don’t know exactly how it works, but we know that it does. If it works in left heart failure, it also [could] work in right heart failure,” said Safdar, who is the director of the Houston Methodist Lung Center, Houston Methodist Hospital, Houston.
The study was independently supported. Lemonjava, Quadery, and Safdar reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
FROM CHEST 2024
Poor Arm Position May Significantly Skew BP Readings
Common arm positions for blood pressure (BP) measurements that stray from guidelines — arm in lap or hanging at side — led to substantial overestimation of hypertension in a study published in JAMA Internal Medicine.
Guidelines for BP measurement recommend arm support on a desk with the midcuff at heart level. Overestimating BP can lead to unnecessary patient follow-up and overtreatment. Hypertension affects approximately 86 million adults in the United States and more than 1 billion people globally.
This study has widespread implications given the number of settings where BP checks are performed and the growth in patients taking their own BP readings at home, said Donald DiPette, MD, who was not part of the research and was asked to comment on the findings. Dr. DiPette is the Distinguished Health Sciences Professor at the School of Medicine, University of South Carolina, Columbia.
Substantial Overestimation
In the crossover, randomized trial of 133 adults, Hairong Liu, MHS, with the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues found that supporting the arm on the lap overestimated systolic BP (SBP) by 3.9 mmHg and diastolic BP (DBP) by 4.0 mm Hg. When the arm hung at the side, readings overestimated SBP by 6.5 mm Hg and DBP by 4.4 mm Hg, with consistent results across subgroups.
Participants were randomly assigned to get a series of BP measurements with the arm positioned in three ways: Supported on a desk; hand supported on lap; and arm unsupported at the side. Because BP readings are intrinsically variable, all had a fourth set of BP measurements with the arm supported on a desk.
Participants’ mean age was 57 years; 48 participants (36%) had SBP of ≥ 130 mm Hg; and 55 participants (41%) had a body mass index of ≥ 30.
Two researcher team staff members conducted all the measurements. They received standardized training and completed a certification test in BP measurement, administered by a study author. Measurements were taken from 9 am to 6 pm using a validated oscillometric BP device (ProBP 2000 Digital Blood Pressure Device, Welch Allyn). Only the right arms were used unless a specific condition was present, such as an open sore.
Study’s Design Sets It Apart
The authors wrote that the design of the study set this work apart. “Earlier studies have shown that unsupported or arm positioning below heart level can overestimate SBP by 4-23 mm Hg and DBP by 3-12 mm Hg.” But the strength of this study is the randomized, crossover design, “which is in contrast to the majority of published studies where the order of arm positions before seated BP measurement was not randomized or not clearly described.”
Dr. DiPette, who says, “I’ve given my career to understanding hypertension,” praised the design as well.
Randomization of which position patients were assigned to first was important because the first reading is often higher than subsequent readings, Dr. DiPette said.
“That makes sense as the person acclimatizes to the environment,” he explained. BP can even vary within the same reading, he noted.
Incorrect Readings for Many Reasons
Incorrect measures are common given the number of settings and number of providers and patients taking blood pressure even with training, certification in the method, and educational materials.
“We recommend taking a blood pressure in any possible setting you can. Because it’s that critical,” he said. “Most of the time it’s taken in busy primary care settings. The pressures are there. Most times it’s only one reading. It’s the medical environment of today.”
He noted that although this study finds overestimation, different arm positions not recommended by guidelines could potentially result in underestimation of hypertension.
“I liken the BP measurement to a laboratory test that has clear treatment implications. We would want the BP measurement to have the same rigorous accuracy as a blood test or radiologic machine,” he said.
Dr. DiPette said more education is needed for patients as well as providers as patients may be monitoring their own BP at home. Patients should also know they can ask for a measurement to be repeated, know the correct arm position recommended by guidelines, and the implications of incorrect readings, he said.
This study was supported by Resolve to Save Lives, which is funded by Bloomberg Philanthropies, the Bill and Melinda Gates Foundation, and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation.
Ms. Liu reported grants from Resolve to Save Lives outside the submitted work. One coauthor reported grants from the National Institutes of Health and personal fees from Kowa, RhythmX AI, and Fukuda Denshi outside the submitted work. Dr. DiPette declared no relevant financial relationships. He was part of a leadership team that developed World Health Organization guidelines on hypertension.
A version of this article first appeared on Medscape.com.
Common arm positions for blood pressure (BP) measurements that stray from guidelines — arm in lap or hanging at side — led to substantial overestimation of hypertension in a study published in JAMA Internal Medicine.
Guidelines for BP measurement recommend arm support on a desk with the midcuff at heart level. Overestimating BP can lead to unnecessary patient follow-up and overtreatment. Hypertension affects approximately 86 million adults in the United States and more than 1 billion people globally.
This study has widespread implications given the number of settings where BP checks are performed and the growth in patients taking their own BP readings at home, said Donald DiPette, MD, who was not part of the research and was asked to comment on the findings. Dr. DiPette is the Distinguished Health Sciences Professor at the School of Medicine, University of South Carolina, Columbia.
Substantial Overestimation
In the crossover, randomized trial of 133 adults, Hairong Liu, MHS, with the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues found that supporting the arm on the lap overestimated systolic BP (SBP) by 3.9 mmHg and diastolic BP (DBP) by 4.0 mm Hg. When the arm hung at the side, readings overestimated SBP by 6.5 mm Hg and DBP by 4.4 mm Hg, with consistent results across subgroups.
Participants were randomly assigned to get a series of BP measurements with the arm positioned in three ways: Supported on a desk; hand supported on lap; and arm unsupported at the side. Because BP readings are intrinsically variable, all had a fourth set of BP measurements with the arm supported on a desk.
Participants’ mean age was 57 years; 48 participants (36%) had SBP of ≥ 130 mm Hg; and 55 participants (41%) had a body mass index of ≥ 30.
Two researcher team staff members conducted all the measurements. They received standardized training and completed a certification test in BP measurement, administered by a study author. Measurements were taken from 9 am to 6 pm using a validated oscillometric BP device (ProBP 2000 Digital Blood Pressure Device, Welch Allyn). Only the right arms were used unless a specific condition was present, such as an open sore.
Study’s Design Sets It Apart
The authors wrote that the design of the study set this work apart. “Earlier studies have shown that unsupported or arm positioning below heart level can overestimate SBP by 4-23 mm Hg and DBP by 3-12 mm Hg.” But the strength of this study is the randomized, crossover design, “which is in contrast to the majority of published studies where the order of arm positions before seated BP measurement was not randomized or not clearly described.”
Dr. DiPette, who says, “I’ve given my career to understanding hypertension,” praised the design as well.
Randomization of which position patients were assigned to first was important because the first reading is often higher than subsequent readings, Dr. DiPette said.
“That makes sense as the person acclimatizes to the environment,” he explained. BP can even vary within the same reading, he noted.
Incorrect Readings for Many Reasons
Incorrect measures are common given the number of settings and number of providers and patients taking blood pressure even with training, certification in the method, and educational materials.
“We recommend taking a blood pressure in any possible setting you can. Because it’s that critical,” he said. “Most of the time it’s taken in busy primary care settings. The pressures are there. Most times it’s only one reading. It’s the medical environment of today.”
He noted that although this study finds overestimation, different arm positions not recommended by guidelines could potentially result in underestimation of hypertension.
“I liken the BP measurement to a laboratory test that has clear treatment implications. We would want the BP measurement to have the same rigorous accuracy as a blood test or radiologic machine,” he said.
Dr. DiPette said more education is needed for patients as well as providers as patients may be monitoring their own BP at home. Patients should also know they can ask for a measurement to be repeated, know the correct arm position recommended by guidelines, and the implications of incorrect readings, he said.
This study was supported by Resolve to Save Lives, which is funded by Bloomberg Philanthropies, the Bill and Melinda Gates Foundation, and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation.
Ms. Liu reported grants from Resolve to Save Lives outside the submitted work. One coauthor reported grants from the National Institutes of Health and personal fees from Kowa, RhythmX AI, and Fukuda Denshi outside the submitted work. Dr. DiPette declared no relevant financial relationships. He was part of a leadership team that developed World Health Organization guidelines on hypertension.
A version of this article first appeared on Medscape.com.
Common arm positions for blood pressure (BP) measurements that stray from guidelines — arm in lap or hanging at side — led to substantial overestimation of hypertension in a study published in JAMA Internal Medicine.
Guidelines for BP measurement recommend arm support on a desk with the midcuff at heart level. Overestimating BP can lead to unnecessary patient follow-up and overtreatment. Hypertension affects approximately 86 million adults in the United States and more than 1 billion people globally.
This study has widespread implications given the number of settings where BP checks are performed and the growth in patients taking their own BP readings at home, said Donald DiPette, MD, who was not part of the research and was asked to comment on the findings. Dr. DiPette is the Distinguished Health Sciences Professor at the School of Medicine, University of South Carolina, Columbia.
Substantial Overestimation
In the crossover, randomized trial of 133 adults, Hairong Liu, MHS, with the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues found that supporting the arm on the lap overestimated systolic BP (SBP) by 3.9 mmHg and diastolic BP (DBP) by 4.0 mm Hg. When the arm hung at the side, readings overestimated SBP by 6.5 mm Hg and DBP by 4.4 mm Hg, with consistent results across subgroups.
Participants were randomly assigned to get a series of BP measurements with the arm positioned in three ways: Supported on a desk; hand supported on lap; and arm unsupported at the side. Because BP readings are intrinsically variable, all had a fourth set of BP measurements with the arm supported on a desk.
Participants’ mean age was 57 years; 48 participants (36%) had SBP of ≥ 130 mm Hg; and 55 participants (41%) had a body mass index of ≥ 30.
Two researcher team staff members conducted all the measurements. They received standardized training and completed a certification test in BP measurement, administered by a study author. Measurements were taken from 9 am to 6 pm using a validated oscillometric BP device (ProBP 2000 Digital Blood Pressure Device, Welch Allyn). Only the right arms were used unless a specific condition was present, such as an open sore.
Study’s Design Sets It Apart
The authors wrote that the design of the study set this work apart. “Earlier studies have shown that unsupported or arm positioning below heart level can overestimate SBP by 4-23 mm Hg and DBP by 3-12 mm Hg.” But the strength of this study is the randomized, crossover design, “which is in contrast to the majority of published studies where the order of arm positions before seated BP measurement was not randomized or not clearly described.”
Dr. DiPette, who says, “I’ve given my career to understanding hypertension,” praised the design as well.
Randomization of which position patients were assigned to first was important because the first reading is often higher than subsequent readings, Dr. DiPette said.
“That makes sense as the person acclimatizes to the environment,” he explained. BP can even vary within the same reading, he noted.
Incorrect Readings for Many Reasons
Incorrect measures are common given the number of settings and number of providers and patients taking blood pressure even with training, certification in the method, and educational materials.
“We recommend taking a blood pressure in any possible setting you can. Because it’s that critical,” he said. “Most of the time it’s taken in busy primary care settings. The pressures are there. Most times it’s only one reading. It’s the medical environment of today.”
He noted that although this study finds overestimation, different arm positions not recommended by guidelines could potentially result in underestimation of hypertension.
“I liken the BP measurement to a laboratory test that has clear treatment implications. We would want the BP measurement to have the same rigorous accuracy as a blood test or radiologic machine,” he said.
Dr. DiPette said more education is needed for patients as well as providers as patients may be monitoring their own BP at home. Patients should also know they can ask for a measurement to be repeated, know the correct arm position recommended by guidelines, and the implications of incorrect readings, he said.
This study was supported by Resolve to Save Lives, which is funded by Bloomberg Philanthropies, the Bill and Melinda Gates Foundation, and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation.
Ms. Liu reported grants from Resolve to Save Lives outside the submitted work. One coauthor reported grants from the National Institutes of Health and personal fees from Kowa, RhythmX AI, and Fukuda Denshi outside the submitted work. Dr. DiPette declared no relevant financial relationships. He was part of a leadership team that developed World Health Organization guidelines on hypertension.
A version of this article first appeared on Medscape.com.
FROM JAMA INTERNAL MEDICINE
Lifestyle Medicine: Not Just for the Wealthy
Primary care clinicians understand that addressing lifestyle-related chronic disease health disparities in minority and lower-income communities is a significant opportunity to alleviate unnecessary suffering. Disparate health outcomes associated with underlying comorbidities during the COVID pandemic exposed the urgency of this problem.
When it comes to delivering evidence-based therapeutic lifestyle behavior interventions to these populations, however, there is a misconception that lifestyle medicine is only for the wealthy. Such a misconception needlessly widens the gap in health disparities because the truth is that everyone deserves access to lifestyle medicine. Fortunately, there are numerous successful examples of delivering these services to underresourced patients. We can all contribute to narrowing health inequities by sourcing increasingly abundant lifestyle medicine resources.
All patients’ lived experiences are unique, and there is a wide range of potential challenges to achieving lifestyle behavior change. Ignoring these obstacles is a disservice to patients and almost certainly results in treatment failure. Requirements to document SDOH have been a tremendous initial step.
The next step is to have conversations with every patient about the powerful outcomes of even small lifestyle changes. All too often, clinicians forgo conversations on lifestyle change with patients affected by adverse SDOH and assume that social obstacles automatically mean that patients are neither willing nor able to attempt behavior modification. Instead, it is an opportunity for clinicians, particularly those certified in lifestyle medicine, to meet patients where they are, work with them to identify solutions, and provide referrals to community-based organizations with resources to help.
Small Steps to Big Changes
Not all lifestyle behavior interventions need to be programmatic or time intensive. Clinicians can guide patients toward simple but specific actions that can make a difference in health outcomes over time. Small steps, like eating one can of beans or two bags of frozen leafy greens each week, are a good start toward adjusted eating patterns. The American College of Lifestyle Medicine offers a whole-food, plant-predominant meal guide to share with patients.
Individuals can increase their physical activity in their living rooms by doing sit-to-stands or balancing on one leg. Deep breathing and establishing a sleep routine are other lifestyle behavior changes without a price tag.
It is true that early adopters of lifestyle medicine often had difficulty practicing in underresourced communities. Those practitioners were forced to operate on a cash-pay basis, making access to care cost-prohibitive for many patients. However, board certification has been available since 2017, and lifestyle medicine is being integrated into medical schools and residency programs. Many such board-certified clinicians now work in large health systems and bill under the usual methods. There are also frameworks, such as the community-engaged lifestyle medicine model, showing how to treat patients affected by adverse SDOH effectively.
For example, patients at risk for malnutrition because of illnesses like chronic kidney disease, cancer, and heart failure receive medically tailored meals and access to a registered dietitian through a partnership between UC San Diego Health and Mama’s Kitchen. In Pennsylvania’s Lehigh Valley, where 1 in 10 of the approximately 700,000 residents face food insecurity, the Kellyn Foundation delivers fresh food through the Eat Real Food Mobile Market and offers whole-food, plant-predominant cooking classes, interactive elementary school programs focused on healthy lifestyle choices, and therapeutic lifestyle-change programs in community locations. Three months after launching new mobile market sites in Allentown, 1200 households were utilizing $15 weekly food vouchers through the program. Lifestyle medicine clinicians serve inner-city and rural areas in independent practices, large health systems, and community-based practice activities.
To improve access to lifestyle medicine in underresourced communities, more clinicians trained and certified in lifestyle medicine are needed. The Health Equity Achieved through Lifestyle Medicine Initiative supports a diverse lifestyle medicine workforce by offering scholarships to clinicians underrepresented in medicine and is working to train and certify at least one physician within each of the 1400 federally qualified health centers where clinicians are on the front lines of delivering care to the most underserved populations.
A meaningful first step for clinicians to address health disparities is to screen patients for and document SDOH. The American Academy of Family Physicians offers useful tools to screen patients, identify community-based resources, and help patients create action plans to overcome health risks and improve outcomes. In a promising trend to better support addressing SDOH in clinical care, the 2024 Medicare Physician Fee Schedule final rule included new codes to support this effort.
Not every patient will be ready or willing to begin a lifestyle medicine treatment plan. Still, all of them will be grateful for the opportunity to decide for themselves. If we are invested in narrowing health inequities, lifestyle medicine and behavior change must be a topic in clinical encounters with all our patients.
Dr. Collings, director of lifestyle medicine, Silicon Valley Medical Development, and past president, American College of Lifestyle Medicine, Mountain View, California, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Primary care clinicians understand that addressing lifestyle-related chronic disease health disparities in minority and lower-income communities is a significant opportunity to alleviate unnecessary suffering. Disparate health outcomes associated with underlying comorbidities during the COVID pandemic exposed the urgency of this problem.
When it comes to delivering evidence-based therapeutic lifestyle behavior interventions to these populations, however, there is a misconception that lifestyle medicine is only for the wealthy. Such a misconception needlessly widens the gap in health disparities because the truth is that everyone deserves access to lifestyle medicine. Fortunately, there are numerous successful examples of delivering these services to underresourced patients. We can all contribute to narrowing health inequities by sourcing increasingly abundant lifestyle medicine resources.
All patients’ lived experiences are unique, and there is a wide range of potential challenges to achieving lifestyle behavior change. Ignoring these obstacles is a disservice to patients and almost certainly results in treatment failure. Requirements to document SDOH have been a tremendous initial step.
The next step is to have conversations with every patient about the powerful outcomes of even small lifestyle changes. All too often, clinicians forgo conversations on lifestyle change with patients affected by adverse SDOH and assume that social obstacles automatically mean that patients are neither willing nor able to attempt behavior modification. Instead, it is an opportunity for clinicians, particularly those certified in lifestyle medicine, to meet patients where they are, work with them to identify solutions, and provide referrals to community-based organizations with resources to help.
Small Steps to Big Changes
Not all lifestyle behavior interventions need to be programmatic or time intensive. Clinicians can guide patients toward simple but specific actions that can make a difference in health outcomes over time. Small steps, like eating one can of beans or two bags of frozen leafy greens each week, are a good start toward adjusted eating patterns. The American College of Lifestyle Medicine offers a whole-food, plant-predominant meal guide to share with patients.
Individuals can increase their physical activity in their living rooms by doing sit-to-stands or balancing on one leg. Deep breathing and establishing a sleep routine are other lifestyle behavior changes without a price tag.
It is true that early adopters of lifestyle medicine often had difficulty practicing in underresourced communities. Those practitioners were forced to operate on a cash-pay basis, making access to care cost-prohibitive for many patients. However, board certification has been available since 2017, and lifestyle medicine is being integrated into medical schools and residency programs. Many such board-certified clinicians now work in large health systems and bill under the usual methods. There are also frameworks, such as the community-engaged lifestyle medicine model, showing how to treat patients affected by adverse SDOH effectively.
For example, patients at risk for malnutrition because of illnesses like chronic kidney disease, cancer, and heart failure receive medically tailored meals and access to a registered dietitian through a partnership between UC San Diego Health and Mama’s Kitchen. In Pennsylvania’s Lehigh Valley, where 1 in 10 of the approximately 700,000 residents face food insecurity, the Kellyn Foundation delivers fresh food through the Eat Real Food Mobile Market and offers whole-food, plant-predominant cooking classes, interactive elementary school programs focused on healthy lifestyle choices, and therapeutic lifestyle-change programs in community locations. Three months after launching new mobile market sites in Allentown, 1200 households were utilizing $15 weekly food vouchers through the program. Lifestyle medicine clinicians serve inner-city and rural areas in independent practices, large health systems, and community-based practice activities.
To improve access to lifestyle medicine in underresourced communities, more clinicians trained and certified in lifestyle medicine are needed. The Health Equity Achieved through Lifestyle Medicine Initiative supports a diverse lifestyle medicine workforce by offering scholarships to clinicians underrepresented in medicine and is working to train and certify at least one physician within each of the 1400 federally qualified health centers where clinicians are on the front lines of delivering care to the most underserved populations.
A meaningful first step for clinicians to address health disparities is to screen patients for and document SDOH. The American Academy of Family Physicians offers useful tools to screen patients, identify community-based resources, and help patients create action plans to overcome health risks and improve outcomes. In a promising trend to better support addressing SDOH in clinical care, the 2024 Medicare Physician Fee Schedule final rule included new codes to support this effort.
Not every patient will be ready or willing to begin a lifestyle medicine treatment plan. Still, all of them will be grateful for the opportunity to decide for themselves. If we are invested in narrowing health inequities, lifestyle medicine and behavior change must be a topic in clinical encounters with all our patients.
Dr. Collings, director of lifestyle medicine, Silicon Valley Medical Development, and past president, American College of Lifestyle Medicine, Mountain View, California, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Primary care clinicians understand that addressing lifestyle-related chronic disease health disparities in minority and lower-income communities is a significant opportunity to alleviate unnecessary suffering. Disparate health outcomes associated with underlying comorbidities during the COVID pandemic exposed the urgency of this problem.
When it comes to delivering evidence-based therapeutic lifestyle behavior interventions to these populations, however, there is a misconception that lifestyle medicine is only for the wealthy. Such a misconception needlessly widens the gap in health disparities because the truth is that everyone deserves access to lifestyle medicine. Fortunately, there are numerous successful examples of delivering these services to underresourced patients. We can all contribute to narrowing health inequities by sourcing increasingly abundant lifestyle medicine resources.
All patients’ lived experiences are unique, and there is a wide range of potential challenges to achieving lifestyle behavior change. Ignoring these obstacles is a disservice to patients and almost certainly results in treatment failure. Requirements to document SDOH have been a tremendous initial step.
The next step is to have conversations with every patient about the powerful outcomes of even small lifestyle changes. All too often, clinicians forgo conversations on lifestyle change with patients affected by adverse SDOH and assume that social obstacles automatically mean that patients are neither willing nor able to attempt behavior modification. Instead, it is an opportunity for clinicians, particularly those certified in lifestyle medicine, to meet patients where they are, work with them to identify solutions, and provide referrals to community-based organizations with resources to help.
Small Steps to Big Changes
Not all lifestyle behavior interventions need to be programmatic or time intensive. Clinicians can guide patients toward simple but specific actions that can make a difference in health outcomes over time. Small steps, like eating one can of beans or two bags of frozen leafy greens each week, are a good start toward adjusted eating patterns. The American College of Lifestyle Medicine offers a whole-food, plant-predominant meal guide to share with patients.
Individuals can increase their physical activity in their living rooms by doing sit-to-stands or balancing on one leg. Deep breathing and establishing a sleep routine are other lifestyle behavior changes without a price tag.
It is true that early adopters of lifestyle medicine often had difficulty practicing in underresourced communities. Those practitioners were forced to operate on a cash-pay basis, making access to care cost-prohibitive for many patients. However, board certification has been available since 2017, and lifestyle medicine is being integrated into medical schools and residency programs. Many such board-certified clinicians now work in large health systems and bill under the usual methods. There are also frameworks, such as the community-engaged lifestyle medicine model, showing how to treat patients affected by adverse SDOH effectively.
For example, patients at risk for malnutrition because of illnesses like chronic kidney disease, cancer, and heart failure receive medically tailored meals and access to a registered dietitian through a partnership between UC San Diego Health and Mama’s Kitchen. In Pennsylvania’s Lehigh Valley, where 1 in 10 of the approximately 700,000 residents face food insecurity, the Kellyn Foundation delivers fresh food through the Eat Real Food Mobile Market and offers whole-food, plant-predominant cooking classes, interactive elementary school programs focused on healthy lifestyle choices, and therapeutic lifestyle-change programs in community locations. Three months after launching new mobile market sites in Allentown, 1200 households were utilizing $15 weekly food vouchers through the program. Lifestyle medicine clinicians serve inner-city and rural areas in independent practices, large health systems, and community-based practice activities.
To improve access to lifestyle medicine in underresourced communities, more clinicians trained and certified in lifestyle medicine are needed. The Health Equity Achieved through Lifestyle Medicine Initiative supports a diverse lifestyle medicine workforce by offering scholarships to clinicians underrepresented in medicine and is working to train and certify at least one physician within each of the 1400 federally qualified health centers where clinicians are on the front lines of delivering care to the most underserved populations.
A meaningful first step for clinicians to address health disparities is to screen patients for and document SDOH. The American Academy of Family Physicians offers useful tools to screen patients, identify community-based resources, and help patients create action plans to overcome health risks and improve outcomes. In a promising trend to better support addressing SDOH in clinical care, the 2024 Medicare Physician Fee Schedule final rule included new codes to support this effort.
Not every patient will be ready or willing to begin a lifestyle medicine treatment plan. Still, all of them will be grateful for the opportunity to decide for themselves. If we are invested in narrowing health inequities, lifestyle medicine and behavior change must be a topic in clinical encounters with all our patients.
Dr. Collings, director of lifestyle medicine, Silicon Valley Medical Development, and past president, American College of Lifestyle Medicine, Mountain View, California, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Which Medication Is Best? VA Genetic Tests May Have the Answer
The US Department of Veterans Affairs (VA) now has a permanent pharmacogenomics service that provides genetic tests to give clinicians insight into the best medication options for their patients.
The tests, which have no extra cost, are available to all veterans, said pharmacist Jill S. Bates, PharmD, MS, executive director of the VA National Pharmacogenomics Program, who spoke in an interview and a presentation at the annual meeting of the Association of VA Hematology/Oncology.
Genetic testing is “a tool that can help optimize care that we provide for veterans,” she said. “Pharmacogenomics is additional information to help the clinician make a decision. We know that most veterans—greater than 90%—carry a variant in a pharmacogenomics gene that is actionable.”
The genetic tests can provide insight into the optimal medication for multiple conditions such as mental illness, gastrointestinal disorders, cancer, pain, and heart disease. According to a 2019 analysis of over 6 years of data, more than half of the VA patient population used medications whose efficacy may have been affected by detectable genetic variants.
For instance, Bates said tests can let clinicians know whether patients are susceptible to statin-associated muscle adverse effects if they take simvastatin, the cholesterol medication. An estimated 25.6% of the VA population has this variant.
Elsewhere on the cardiac front, an estimated 58.3% of the VA population has a genetic variant that increases sensitivity to the blood thinner warfarin.
Testing could help psychiatrists determine whether certain medications should not be prescribed—or should be prescribed at lower doses—in patients who’ve had adverse reactions to antidepressants, Bates said.
In cancer, Bates said, genetic testing can identify patients who have a genetic variant that boosts toxicity from fluoropyrimidine chemotherapy treatments, which include capecitabine, floxuridine, and fluorouracil. Meanwhile, an estimated 0.9% will have no reaction or limited reaction to capecitabine and fluorouracil, and 4.8% will have hypersensitivity to carbamazepine and oxcarbazepine.
Tests can also identify a genetic variant that can lead to poor metabolism of the chemotherapy drug irinotecan, which is used to treat colon cancer. “In those patients, you’d want to reduce the dose by 20%,” Bates said. In other cases, alternate drugs may be the best strategy to address genetic variations.
Prior to 2019, clinicians had to order pharmacogenomic tests outside of the VA system, according to Bates. That year, a donation from Sanford Health brought VA pharmacogenomics to 40 pilot sites. Since then, more than 88,000 tests have been performed.
The VA has now made its pharmacogenomic program permanent, Bates said. As of early September, testing was available at 139 VA sites and is coming soon to 4 more. It’s not available at another 23 sites that are scattered across the country.
A tool in the VA electronic health record now reminds clinicians about the availability of genetic testing and allows them to order tests. However, testing isn’t available for patients who have had liver transplants or certain bone marrow transplants.
The VA is working on developing decision-making tools to help clinicians determine when the tests are appropriate, Bates said. It typically takes 2 to 3 weeks to get results, she said, adding that external laboratories provide results. “We eventually would like to bring in all pharmacogenomics testing to be conducted within the VA enterprise.”
Bates reported that she had no disclosures.
The US Department of Veterans Affairs (VA) now has a permanent pharmacogenomics service that provides genetic tests to give clinicians insight into the best medication options for their patients.
The tests, which have no extra cost, are available to all veterans, said pharmacist Jill S. Bates, PharmD, MS, executive director of the VA National Pharmacogenomics Program, who spoke in an interview and a presentation at the annual meeting of the Association of VA Hematology/Oncology.
Genetic testing is “a tool that can help optimize care that we provide for veterans,” she said. “Pharmacogenomics is additional information to help the clinician make a decision. We know that most veterans—greater than 90%—carry a variant in a pharmacogenomics gene that is actionable.”
The genetic tests can provide insight into the optimal medication for multiple conditions such as mental illness, gastrointestinal disorders, cancer, pain, and heart disease. According to a 2019 analysis of over 6 years of data, more than half of the VA patient population used medications whose efficacy may have been affected by detectable genetic variants.
For instance, Bates said tests can let clinicians know whether patients are susceptible to statin-associated muscle adverse effects if they take simvastatin, the cholesterol medication. An estimated 25.6% of the VA population has this variant.
Elsewhere on the cardiac front, an estimated 58.3% of the VA population has a genetic variant that increases sensitivity to the blood thinner warfarin.
Testing could help psychiatrists determine whether certain medications should not be prescribed—or should be prescribed at lower doses—in patients who’ve had adverse reactions to antidepressants, Bates said.
In cancer, Bates said, genetic testing can identify patients who have a genetic variant that boosts toxicity from fluoropyrimidine chemotherapy treatments, which include capecitabine, floxuridine, and fluorouracil. Meanwhile, an estimated 0.9% will have no reaction or limited reaction to capecitabine and fluorouracil, and 4.8% will have hypersensitivity to carbamazepine and oxcarbazepine.
Tests can also identify a genetic variant that can lead to poor metabolism of the chemotherapy drug irinotecan, which is used to treat colon cancer. “In those patients, you’d want to reduce the dose by 20%,” Bates said. In other cases, alternate drugs may be the best strategy to address genetic variations.
Prior to 2019, clinicians had to order pharmacogenomic tests outside of the VA system, according to Bates. That year, a donation from Sanford Health brought VA pharmacogenomics to 40 pilot sites. Since then, more than 88,000 tests have been performed.
The VA has now made its pharmacogenomic program permanent, Bates said. As of early September, testing was available at 139 VA sites and is coming soon to 4 more. It’s not available at another 23 sites that are scattered across the country.
A tool in the VA electronic health record now reminds clinicians about the availability of genetic testing and allows them to order tests. However, testing isn’t available for patients who have had liver transplants or certain bone marrow transplants.
The VA is working on developing decision-making tools to help clinicians determine when the tests are appropriate, Bates said. It typically takes 2 to 3 weeks to get results, she said, adding that external laboratories provide results. “We eventually would like to bring in all pharmacogenomics testing to be conducted within the VA enterprise.”
Bates reported that she had no disclosures.
The US Department of Veterans Affairs (VA) now has a permanent pharmacogenomics service that provides genetic tests to give clinicians insight into the best medication options for their patients.
The tests, which have no extra cost, are available to all veterans, said pharmacist Jill S. Bates, PharmD, MS, executive director of the VA National Pharmacogenomics Program, who spoke in an interview and a presentation at the annual meeting of the Association of VA Hematology/Oncology.
Genetic testing is “a tool that can help optimize care that we provide for veterans,” she said. “Pharmacogenomics is additional information to help the clinician make a decision. We know that most veterans—greater than 90%—carry a variant in a pharmacogenomics gene that is actionable.”
The genetic tests can provide insight into the optimal medication for multiple conditions such as mental illness, gastrointestinal disorders, cancer, pain, and heart disease. According to a 2019 analysis of over 6 years of data, more than half of the VA patient population used medications whose efficacy may have been affected by detectable genetic variants.
For instance, Bates said tests can let clinicians know whether patients are susceptible to statin-associated muscle adverse effects if they take simvastatin, the cholesterol medication. An estimated 25.6% of the VA population has this variant.
Elsewhere on the cardiac front, an estimated 58.3% of the VA population has a genetic variant that increases sensitivity to the blood thinner warfarin.
Testing could help psychiatrists determine whether certain medications should not be prescribed—or should be prescribed at lower doses—in patients who’ve had adverse reactions to antidepressants, Bates said.
In cancer, Bates said, genetic testing can identify patients who have a genetic variant that boosts toxicity from fluoropyrimidine chemotherapy treatments, which include capecitabine, floxuridine, and fluorouracil. Meanwhile, an estimated 0.9% will have no reaction or limited reaction to capecitabine and fluorouracil, and 4.8% will have hypersensitivity to carbamazepine and oxcarbazepine.
Tests can also identify a genetic variant that can lead to poor metabolism of the chemotherapy drug irinotecan, which is used to treat colon cancer. “In those patients, you’d want to reduce the dose by 20%,” Bates said. In other cases, alternate drugs may be the best strategy to address genetic variations.
Prior to 2019, clinicians had to order pharmacogenomic tests outside of the VA system, according to Bates. That year, a donation from Sanford Health brought VA pharmacogenomics to 40 pilot sites. Since then, more than 88,000 tests have been performed.
The VA has now made its pharmacogenomic program permanent, Bates said. As of early September, testing was available at 139 VA sites and is coming soon to 4 more. It’s not available at another 23 sites that are scattered across the country.
A tool in the VA electronic health record now reminds clinicians about the availability of genetic testing and allows them to order tests. However, testing isn’t available for patients who have had liver transplants or certain bone marrow transplants.
The VA is working on developing decision-making tools to help clinicians determine when the tests are appropriate, Bates said. It typically takes 2 to 3 weeks to get results, she said, adding that external laboratories provide results. “We eventually would like to bring in all pharmacogenomics testing to be conducted within the VA enterprise.”
Bates reported that she had no disclosures.