Hello! I hope you like the new blog design and that you will be able to use it more easily during your consultations to find guidelines or an article of which you do not remember the details. Here is the medical news post of the week. It will not be very long today, have a pleasant reading!
1/ COVID-19
The JAMA has published an article about the interpretation of the results of Sars-CoV2 screening tests. We can see how screening tests should be used depending on the period since the infection.
Guidelines about pregnancy during the pandemic have been published by the Royal College of Obstetricians and Gynaecologists. The authors confirm that the most at-risk period of the pregnancy regarding severity is the 3rd trimester. Of course, usual care remains essential and follow-up should not be interrupted. For pregnant patients with a suspicion of COVID, preventive anticoagulation is not systematic and depends on the number of initial risk factors (prophylactic anticoagulation from 3 risk factors onwards, from a list determined by NICE here).
The French Public Health High Council (HCSP, document in French) has published advice about re-use of single-use masks, essentially from data from the hospital hygiene society. The authors find that the useful methods for sterilization in hospitals are water vapour (121 °C = 250 °F during 20 minutes), UV light at 254 nanometers and low temperature sterilization with hydrogen peroxide. Other methods that can be used in a community setting are currently assessed, such as micro-wave heating after humidification (for how long?) or dry/wet heating at 60-70 °C (140-158 °F). These techniques seem to be able to obtain a good sterilization without altering the filtration properties, but they are still insufficiently assessed to this day. The HSCP finally advises not to recycle single-use masks, considering that supply shortages are about to end in France.
In the absence of better studies, a French survey has evaluated renunciation of care from patients with chronic diseases during lockdown, from a representative sample of the French population. According to the report of the survey, 32% of patients were having at least one chronic disease and among them 46% had waived a consultation in community setting and 12% in hospital setting!
2/ Cardiovascular medicine
After the 2018 European guidelines (previous blog post in French here) and the 2019 NICE guidelines (previous blog post in French here), here are the new guidelines about high blood pressure from the International Society of Hypertension. They are published in an innovative and interesting format, with 2 levels of guidelines: "essential" and "optimal" standards of care.
Regarding diagnosis, there is nothing new, the threshold is at 140/90 mmHg at the practice (average of the last 2 measures out of 3 at 1-minute intervals, but only one is enough if under 130/85), to be confirmed with home measures (24-hours ABPM or self-checks): 2 measures at 1-minute intervals in the morning before taking medication and at night time, for 3 to 7 days. Little reminder about the medications that can increase blood pressure but easily overlooked: combined OCP, antidepressants, paracetamol.
Regarding investigations, they should systematically include: Na, K, creatinine levels, urine dipstick screening for proteinuria and ECG; and if possible lipids and fasting glucose (and not HbA1c as per European guidelines). Uric acid and LFTs can be added. The rest is only recommended in case of a suspicion of secondary damage to organs. Please note that TSH is part of secondary hypertension investigations.
Regarding BP targets, they are easy to understand.
- "Essential" standard of care: a decrease of 20/10 mmHg, ideally to achieve 140/90 mnmHg.
- "Optimal" standard of care: before 65, 130/80 (but over 120/70) and after 65, 140/90 but it can be lower than this last figure if medications are well tolerated (so we go back to lower targets after 65 rather than after 80). Dual therapy is advised from the start, using single-pill combinations, unless BP < 160/100 mmHg AND no other risk factor (age >65, HR >80/min, BMI >25, diabetes, dyslipidaemia, cardiovascular concerns in FMHx, early menopause, active smoker, adverse psychological or social context).
Regarding BP targets, they are easy to understand.
- "Essential" standard of care: a decrease of 20/10 mmHg, ideally to achieve 140/90 mnmHg.
- "Optimal" standard of care: before 65, 130/80 (but over 120/70) and after 65, 140/90 but it can be lower than this last figure if medications are well tolerated (so we go back to lower targets after 65 rather than after 80). Dual therapy is advised from the start, using single-pill combinations, unless BP < 160/100 mmHg AND no other risk factor (age >65, HR >80/min, BMI >25, diabetes, dyslipidaemia, cardiovascular concerns in FMHx, early menopause, active smoker, adverse psychological or social context).
Regarding drugs:
- First line: ACEi (or ARB)+calcium-channel blocker low dose then full dose if needed.
- Then triple therapy by adding a thiazide-like diuretic rather than a thiazide-type diuretic (this is logical according to current evidence).
- If still not under control, it is a drug-resistant hypertension: spironolactone should be added, providing K<4.5 and GFR>45 mL/min.
- And if needed, one can use: amiloride, doxazosin, eplenerone, clonidine or beta-blockers. Beta-blockers remain indicated in case of coronaropathy, AF, HF or pregnancy.
Considering what has already been discussed in the previous reviews from Lancet and JAMA (previous blog post in French here), thiazide diuretics are the most cost-efficient drugs, so we can regret that ACEi+thiazide-like combinations are only promoted in case of stroke, HF and very old patients (I would not have advised diuretics in very old patients...). For black patients, an alternative is possible for first-line treatment with the calcium-channel blocker + thiazide-like diuretic combination. (But thiazide-type diuretics are an old unprofitable drug class, I would not be surprised if there was some kind of lobbying to push them out to the benefit of other drug classes).
- Then triple therapy by adding a thiazide-like diuretic rather than a thiazide-type diuretic (this is logical according to current evidence).
- If still not under control, it is a drug-resistant hypertension: spironolactone should be added, providing K<4.5 and GFR>45 mL/min.
- And if needed, one can use: amiloride, doxazosin, eplenerone, clonidine or beta-blockers. Beta-blockers remain indicated in case of coronaropathy, AF, HF or pregnancy.
Considering what has already been discussed in the previous reviews from Lancet and JAMA (previous blog post in French here), thiazide diuretics are the most cost-efficient drugs, so we can regret that ACEi+thiazide-like combinations are only promoted in case of stroke, HF and very old patients (I would not have advised diuretics in very old patients...). For black patients, an alternative is possible for first-line treatment with the calcium-channel blocker + thiazide-like diuretic combination. (But thiazide-type diuretics are an old unprofitable drug class, I would not be surprised if there was some kind of lobbying to push them out to the benefit of other drug classes).
Regarding other drugs:
- antiplatelet therapy is only recommended in secondary prevention, whatever the other comorbidities are.
- LDL-cholesterol targets are: <0.55 g/L (1.42 mmol/L) or <0.7 g/L (1.81 mmol/L) in case of coronaropathy (depending on the paragraph of the document...), <0.7 g/L (1.81 mmol/L) in case of stroke, diabetes or high risk, <1.15 g/L (2.97 mmol/L) if moderate CV risk.
- no treatment for hyperuricemia without symptoms.
Regarding HBP crisis, they recommend labetalol (pretty consensual) or nicardipine (less consensual, see previous blog post in French here).
- antiplatelet therapy is only recommended in secondary prevention, whatever the other comorbidities are.
- LDL-cholesterol targets are: <0.55 g/L (1.42 mmol/L) or <0.7 g/L (1.81 mmol/L) in case of coronaropathy (depending on the paragraph of the document...), <0.7 g/L (1.81 mmol/L) in case of stroke, diabetes or high risk, <1.15 g/L (2.97 mmol/L) if moderate CV risk.
- no treatment for hyperuricemia without symptoms.
Regarding HBP crisis, they recommend labetalol (pretty consensual) or nicardipine (less consensual, see previous blog post in French here).
The JAMA discusses the use of SGLT-2 inhibitors for heart failure treatment in a model based on US data. The authors estimate that 70% of patients with HF could be potential candidates for these drugs (which seems a lot to me for what should be considered as a third-line treatment, to be used after beta-blockers, ACEi and aldactone). They also think that 30 000 deaths could be avoided. It is probably necessary to study more this treatment for non-diabetes indications before using it massively considering its side effects (previous blog post in French here).
3/ The qualitative study by @DrePetronille
We speak more and more about caregivers, but how can the disease disturb the couple relationship? This is what this qualitative study tries to assess by investigating the couple relationship modifications for patients with a cardiovascular disease. According to the study enrolees (sick people and their partner), the disease affected their relationship through different ways: emotional and communication disconnection (due to the disease stress), role changes (burden for the caregiver, loss of usual role for the sick one), overprotection of the patient, lifestyle changes and for some enrolees, positive relationship changes through new ways of communicating. Identified needs were to include partners in the care and patient education, through healthcare professionals or meeting other couples. At last, couples wanted to be helped in their modified relationship and not only on pure medical matters.
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See you next week
(free translation in English by @carttom)
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