Dragi Weekly No. 273 : COVID-19, antihypertensive medication reduction, withdrawal of ICS (ERS guidelines), hormone replacement therapy, thyroid cancer, liraglutide/obesity

Hello! I hope that, as usual, you are doing well and I thank you for your loyalty and your positive feedback. Here are the selected articles for this week, have a good reading!

1/ COVID-19

Of course, we are going to start by talking about the withdrawal of the Lancet article that we spoke about few weeks ago. I did not talk too much about the study methods simply because the week prior, 3 other studies already had shown the uselessness of the chloroquine. So this Lancet article, whether approved or withdrawn, was not changing anything.

By the way, the results of the British Recovery study were presented. It was a study randomizing hospitalized COVID patients in 5 arms: standard of care, lopinavir-ritonavir, dexamethasone, hydroxychloroquine or azithromycin. With 1,500 patients in the hydroxychloroquine arm and 3,000 in the standard of care arm, there was no difference in mortality at day 28 between the 2 groups (respectively 25.7% vs 23.5%). One can still persist with hydroxychloroquine, but at some stage, it becomes unreasonable.

A study in Lancet Public Health looked at the non-hospital cardiac arrest events in the Paris region during COVID epidemic. So, the figure speaks by itself, and mortality followed the same trend. It is probably the collateral effects of COVID, associated with the inaccessibility of some healthcare services and with the renouncement to healthcare during that time.

2/ Cardiovascular medicine

A randomized controlled trial in the JAMA evaluated deprescribing antihypertensive medication for patients over 80 y.o. with a SBP < 150 mmHg vs. control group. Respectively, in each group, there were 86% and 89% of patients with a SBP < 150 mmHg at week 12 ; medication reduction was maintained in 66% of the patients from the intervention group. I hope that the authors will soon provide data with a longer follow-up and on cardiovascular or mortality clinical outcomes.

3/ Repsiratory medicine

The European Respiratory Society provides guidelines on withdrawal of inhaled corticosteroids for COPD patients. The American society suggested this option of medication reduction as well (see here). ERS recommends deprescribing ICS for patients with no recent exacerbation and having an eosinophil count under 300 / µL. In case of medication reduction, a long-acting bronchodilatator (LABA or LAMA) should be kept as a preventer.

4/ Gynaecology

Following a Lancet article about the risks of hormone replacement therapy, the European Medicines Agency was asked to start an inquiry about the risk increase of breast cancer with HRT up to 10 years after its discontinuation (except for low dose vaginal estrogens which seemed to be safe). These suspicions were validated by the EMA and from now on, they should figure in the corresponding medicines' safety information sheets.

A randomized controlled trial evaluated the impact of a shared-decision making tool regarding the choice between vaginal birth and C-section among patients with a past history of C-section, hoping reducing the rate of unnecessary surgical procedures. The study included over 1,400 patients and the tool only managed to decrease the number of C-sections by 3% (43% vs 46%). There was no significant difference between the 2 groups regarding maternal and neonatal consequences. Overall, this tool does not work, but remains interesting (see the study appendix ; too long to be copied here unfortunately). 

5/ Endocrinology and nutrition

A new article discusses the overdiagnosis of thyroid cancer (see previous discussed article here). In France, the overdiagnosis of thyroid cancers is estimated at 83% between 2008 and 2012. The estimated mortality of this cancer is less than 1 per 100,000 patients. 

A randomized controlled trial evaluated the efficacy of liraglutide for weight reduction in non diabetic obese teenagers. The authors conclude that the treatment is efficient, with a significant BMI decrease of 0.37 SD (standard deviation) after 56 weeks: that equals to a BMI decrease of around 5 points for patients with an initial average BMI of 35. However, as soon as liraglutide was stopped, weight was going back almost up to the initial value 6 months after cessation. For the control group, after stopping the placebo, BMI also increased so there was still a difference between the 2 groups, but the result on the weight by itself remains unsatisfactory anyway...

Finished! Do not forget Facebook, Twitter and the newsletter! See you next week!

@Dr_Agibus (free translation by @carttom).

Dragi Weekly No. 272 : Guidelines for travelers, COVID (vitamin D, hydroxychloroquine), Lyme disease, mesothelioma, dementia

Hello! This is the end of the semester for our residents, I hope next semester will be more "usual", even though already short of one month. Here are the articles of the week, good reading!

1/ COVID-19

The French Academy of Medicine (link in French) takes position in favor of a vitamin D deficiency screening for COVID patients older than 60 and then a treatment if deficiency is proven ; and in favor of a treatment without prior screening for COVID patients younger than 60. This advice relies on a correlation that was found in only one study. For years, vitamin D has been promoted with many advantages but supplementation (blog post in French) does not manage to improve clinical outcomes. Only in respiratory diseases, in case of deficiency, it seems there are less complications in COPD and asthma patients (blog posts in French) after supplementation.

Following the Lancet article last week, the French High Council for Public Health (link in French) advises not to use hydroxycholoroquine to treat COVID-19 anymore.

In order to confirm this position, here is a systematic review that was published in Annals of Internal Medicine. The authors did not find any published study about using (hydroxy)chloroquine as a preventive treatment. The benefits from this medication on mortality, clinical aggravation, intubation needs and symptom resolution were globally similar to those from conventional treatment. The side effects were mainly a QT-interval increase among patients with (hydroxy)chloroquine, but without any clinical consequences. I think that, in a study, one stops the treatment and does not wait for the ventricular arrhythmia to happen.

And for those performing nasopharyngeal swabs, the best way to do it is to aim for the ear lobe.

2/ Cardiovascular diseases

For patients with infrarenal aortic aneurysms of small size (< 50 mm), a randomized controlled trial tested the use of doxycycline 100 mg daily during 2 years. And we have to admit that it does not work to slow down the progress of the aneurysm. Next time, they may try hydroxycholoroquine!
After all, both are malaria medications so why not?

3/ Infective diseases

Perfect transition to speak about 2020 health guidelines for travellers (link in French), published by the High Council for Public Health. Compared to 2019 ones (blog post in French), I have not found any changes. So, for this year, I want to speak about venous thromboembolic events prevention. Class II compression stockings are advised for people with risk factors or not able to wander in the plane during flights over 6 hours long. LMWH do not possess any valid indication but could sometimes be prescribed if stockings cannot be used or in case of very high risk, notably in case of past medical history of travel-related DVT (see here, blog post in French).

Now let us talk about Lyme disease, with a BMJ review. Erythema migrans appears between few days to few weeks after the bite, unlike the bite rash which appears between few hours to few days and disappears during the next few days (and which does not need any treatment). Erythema migrans has a clear centre only for Borellia Afzelli (which is present in Europe in 60% of cases), whereas B. Burgdorferi (in the USA) and B. garinii are responsible for homogeneous erythemas. So, in more than half of cases, if it is homogeneous, it is still a Lyme disease! Doxycycline is now the first-line treatment, as described in French and English guidelines. Chronic symptoms attributed to the Lyme borreliosis happen in 5-10% of patients who were treated and are still symptomatic. Criteria are 1/ documented infection at an early or late stage ; 2/ improvement after treatment ; 3/ onset within 6 months and for at least 6 months of musculoskeletal impairment, cognitive impairment or fatigue. In these cases, antibiotic treatment does not work and is not advised because the disease is not "active", it is only sequelae symptoms. Some scientific societies offer, on a case-by-case basis, 3 to 6 weeks of antibiotics once, suspecting an insufficient early treatment or a secondary infection. Regarding treatment after the bite, only the "International society of Lyme disease" recommends it systematically ; otherwise it is more about careful monitoring and treatment only if erythema migrans appears (for Americans, according to some criteria seen here).

4/ Respiratory medicine

European guidelines about mesothelioma management have just been published. I confess that this is not really general practice... but there is a small part about screening. And in at-risk populations, standard X-Rays were the most used. So, we now know that the existence of pleural plaques is only a sign of asbestos exposure and not an additional risk factor (even though it is correlated with cancer since mesothelioma is linked to asbestos). Injected CT-scan is to be recommended as more precise but we lack studies on the screening benefits (see French guidelines here).

5/ Neurology

My grandmother knew it: eating fish is good for memory! This article speaks about the Mediterranean diet and finds out that a diet with a lot of fish decreases the risk of dementia and slows down the progress of memory impairment. This result comes from ancillary analyses from 2 current randomized trials studying the progress of macular degeneration.

After the failure of the ASPREE study to show efficacy of aspirin in primary prevention on global and cardiovascular mortality (blog post in French), here is the ASPREE analysis about the efficacy of aspirin on the risk of cognitive disabilities: no benefit on reducing the risk of dementia either.

This is the end for this week. To avoid missing anything, you should subscribe on Facebook, Twitter or to the e-mail newsletter if not already done. You have to put your e-mail address in the top right field of this page and confirm the subscription in an e-mail entitled "FeedBurner Email Subscriptions" that will be sent to you and may land in your junk folder.

Have a good day, good luck to the new residents and see you next week!

@Dr_Agibus (free translation by @carttom)

Dragi Weekly No. 271: COVID (hydroxychloroquine, remdesivir, olfactory dysfunction), venous thromboembolic diseases (NICE guidelines), surveillance colonoscopy, PrEP, OGTT, insulin

Hello! As always, quite a few news around COVID this week, but also some other interesting papers. Have a good reading!

1/ COVID-19

To abandon hydroxcychloroquine once and for all, The Lancet published a study based on the registries of more than 600 hospitals worldwide to compare mortality and the onset of arrythmias among patients with hydroxychloroquine (or chloroquine) alone or in association with azithromycin versus patients without any of those medications. Out of 96,000 included patients, around 15,000 had one of these medications. The authors found that, after adjusting on severity and other confounding factors, patients who were treated with hydroxychloroquine had a higher risk of death (18% vs 9.3%, NNH=12) and it was even worse with hydroxychlorquine + azithromycin (22% vs 9.3%, NNH = 8). We can also observe an increase in ventricular arrythmias for patients with those medications. Overall, it is not a randomized controlled trial, but those who treated their patients with compassionate use of hydroxychloroquine should have waited for more solid data. The major risk factors associated with an increase of mortality on top of these medications were smoking, cardiovascular diseases and COPD, whereas the use of ACEi seemed to be a protective factor.

Let us move on to a randomized controlled trial regarding remdesivir, that was published in the NEJM. Firstly, it is a study that was not funded by the pharmaceutical industry. Included patients were COVID+ with a lower respiratory tract infection (so not all COVID+ patients). The main endpoint was the time to recovery (i.e. the time to get out of the necessity of an hospitalization with active care). We can also see that they modified the primary endpoint during the study, but they do not hide it. The results are intermediate results of a still ongoing study, but the authors have reached the required number of events (recovery). There was not any adjustment on the number of tests, so we only look at the primary outcome. The statistical analysis plan was using the O'Brien and Fleming method for intermediate analyses: overall the alpha-risk is at 5%, but at the first intermediate analysis the significance threshold was 0.0001 for example, then 0.001 at the next one and the last 0.0489, so all in all the sum makes 5%. But we do not know what intermediate level the authors used for the final analysis of their study. In the end, over 1,000 patients were randomized (50% with HBP, 30% with diabetes, 30% with obesity). The recovery was faster with remdesivir: 11 days versus 15 days with placebo, p-value <0.001 (apparently, low enough to be considerated valid with the statistical conditions described above for the intermediate analysis). But there was not less mortality. Overall, this treatment seems to be efficient to reduce the length of hospital stay by 4 days (which is not that much) without a proven effect on mortality now, but maybe the results at the end of the follow-up will bring more precision on this topic.

The French Health Authority (link in French here) published guidance on rapid serology tests. Regarding the rapid screening tests in pathology lab, the indications are the same than the normal serology tests (see here). Regarding the point-of-care tests, the Health Authority has not found any published study about them. Even though these latter tests could be an option for diagnosis catching-up for patients who do not have access to a pathology lab or who stay symptomatic despite a negative PCR or who could not get a PCR test, the Health authority recommends that a normal serology test should be systematically performed to confirm the result of a positive POC test (and same for a negative POC tests, but it is only advised).

So, how many people have suffered from COVID? This JAMA study, performed in Los Angeles, found out that, among a representative sample of 1,700 individuals who accepted to be screened, 13% had fever with cough, 9% fever with shortness of breath and 6% dysosmia or dysgeusia. So, authors concluded that only 4.5% of the population suffered from COVID.

Another study in the JAMA about the olfactive impairment with COVID. It allows to discover lots of words to identify olfactive impairment: orthonasal, retronasal impairements, phantosmia, parosmia, parageusia. If the impairment is acute in a viral context, COVID can be an explanation. If the impairment is progressive with a fluctuating nasal obstruction, it is probably a naso-sinusal aetiology. If the impairment is progressive, non fluctuating, in older people with loss of memory, it is probably neuro-degenerative. At last, if the impairment is post-traumatic, it is usually brutal with a severe anosmia. Regarding the management of olfactive impairment due to COVID, the authors suggest to: 1/ put smoking detectors in the house and to verify expiry dates on food before eating it; 2/ try olfactive rehabilitation by sniffing lemon, rose, eucalyptus etc, 20 seconds each, twice daily for at least 3 months; 3/ try oral omega-3 and intranasal vitamin A.

2/ Respiratory medicine

The NICE has published guidelines about venous thromoboembolic diseases. Nothing new compared to the European and French guidelines we spoke about here (link in French). The authors recommend the use of the PERC criteria to rule out a pulmonary embolism in case of low-risk and the use of D-dimers age-adjusted threshold for patients over 50. They recommend against cancer screening for idiopathic events without any other symptoms. The advised first-line treatments are apixaban and rivaroxaban, for a duration of 3 months for the events with an identified cause ; for an unknown duration, depending on the risk-benefits balance for events without. For patients refusing long-term anticoagulation, the authors suggest using low-dose aspirin.

3/ Gastro-enterology

After the discussion about bowel cancer screening (link in French here), here comes a BMJ article discussing the colonoscopy surveillance and when to stop it. So, if a colonoscopy was indicated and polyps were found, what should the surveillance be?

- For 1 or 2 sessile polyps or adenomas < 10 mm, return to non-invasive screening tests is advised.
- From 3 of them (English guidelines' threshold is at 5), a 3-year colonoscopy is recommended (if it is only sessile polyps, returning to non-invasive screening can be considered).
Going back to non-invasive testing means waiting for 10 years after the colonoscopy before restarting any test! Only American guidelines recommend a colonoscopy surveillance every 3 or 10 years, depending on the situation. The former is also what I usually see for my patients in France, but the return back to non-invasive testing is motivated by the low risk (<0.5%) of severe complications during colonoscopies that can add up with repeated colonoscopies and starts to be significant.
- In the other situations (adenomas over 10 mm or with high-grade dysplasia; or sessile polyps > 10 mm or with any grade of dysplasia): a 3-year colonoscopy surveillance is recommended.

4/ Infective diseases

In the PrEP context (link in French), a new preventive treatment of the HIV infection is currently under development: cabetogravir, which has a 8-week lasting effect. A randomized controlled trial among men (and transsexuals) who have sex with men, compared IV cabotegravir to oral Truvada, which is the current advised drug for PrEP. After around 4 years of treatment, in an intermediate analysis, 0.38% patients with cabotegravir had a seroconversion versus 1.21% with Truvada. But 80% of the patients with cabotegravir had side effects versus 30% with Truvada. Let us wait for the final publication of the results now.

5/ Diabetology

Can a biologist tell me how OGTT tubes during pregnancy are centrifugated? It is because this study finds that glucose levels are higher in case of an early centrifugation compared to a late one: early centrifugation could lead to increase the number of gestational diabetes diagnoses by 11.6%!

A JAMA article speaks about the role of the insulin in uncontrolled type 2 diabetes. The authors recommend not to delay insulin initiation when initial HbA1c is over 9% = 75 mmol/mol (and not 10% =  86 mmol/mol as guidelines say), because non-insulin treatments only lower HbA1c by 1.6%  = 5.5 mmol/mol on average. This is insufficient to go under the 8% = 64 mmol/mol threshold, that seems to be associated with less mortality and less complications (please note that the authors do not call for a strict control (link in French), which has no evident benefit).

Thanks for your loyalty, let us meet again next week for the next Dragi Webdo!

@Dr_Agibus (free translation by @carttom)

Dragi Webdo n° 270: COVID-19 (HCSP, SFP, hydroxychloroquine, PCR), NSAIDS and infections, knee OA, gynaecological exam

Welcome for this first Dragi Weekly post-lockdown! I hope that you and your patients have enough masks to protect yourselves. We have already written about it, but take care of yourself. The French High Health Authority has published "quick answers" on this topic: healthcare professionals distress: prevent, identify, guide (here in French). Happy reading !

1/ COVID-19

To begin with, I will share here the link (in French) of the atoute website from Dr. Dupagne, because it is very comprehensive and interesting.

Let us move on with hydroxychloroquine. In this NEJM paper, 1400 patients with a severe form of COVID received hyxdroxychloroquine or standard care, without randomization, in an American hospital. After inverse probability weighting according to the propensity score, no link was found between using hydroxychloroquine and the risk of death or orotracheal intubation. OK, but this is not randomized.

In an article from the BMJ, the outcome for hospitalized COVID patients with pneumonia receiving oxygen (but without criteria for ICU) was assessed in France. 84 patients received hydroxychloroquine out of 181 total patients, without randomization. At day 21, 76% of patients who received hydroxychloroquine were transferred to ICU (and 11% of deaths) versus 75% in the control group (and 9% of deaths). Once again, no statistical difference.

A retrospective study in the JAMA compared mortality of COVID patients who received azithromycin, hydroxychloroquine, both of them or neither of them. Once again, no difference in mortality between the different patient groups after adjusting on confounding factors.

So here comes a randomized controlled trial of 150 Chinese hospitalized patients with a moderate to mild COVID, receiving hydroxycholorquine + standard of care versus standard of care only. At day 28, no change to a more severe COVID form was found in around 80% of patients from both groups, whatever the treatment plan was, with no difference between the 2 groups. Adverse effects occur in 30% of patients with hydroxychloroquine versus 10% of patients without it. So, not only this medication is inefficient, even for low-severity patients, but it exposes them to adverse effects. This study was randomized so it is time now to try other molecules to fight COVID (and I send you back to this editorial by P. Glasziou about the "waste in COVID-19  research").

The French colleges of paediatricians (link in French here) have proposed an algorithm about the management of kids with a suspicion of COVID-19 and PCR indications (it applies from kindergartens to elementary schools, but it will prove to be some sports to do a swab to a child under 5). Globally, the PCR has to be done in case of symptoms if there is a COVID patient among close relatives or if there is no clear cause in case of no obvious contagion.

The French High Council of Public Health (in French here) has published guidelines for people with a suspicion of COVID as past medical history. If one of these people (patient A) is in contact with a COVID+ person (patient B), there are 2 possibilities:

- if patient A had a PCR positive once, no need for quarantine

- if patient A did not have a confirmed diagnosis by PCR, a serology is advised to establish the status regarding COVID. Quarantine is only advised if the serology does not show a previous infection.

Some data from BMJ about the lab tests for COVID: PCR has a sensibility between 70% and 98% in a study, but only 63% if we just look at the figure for nasopharyngeal swab. A table to compute the post-PCR test probability for a positive or negative result based on the clinical pre-test probability is given. Pre-test probability algorithm are seldom used in France (except for pulmonary embolism).

Pre-test probability	PCR negative Post-test probability	PCR positive Post-test probability
5%	1.6%	42%
15%	5%	71%
25%	10%	82%
50%	24%	93%
75%	49%	98%
90%	74%	99%

In the French study CORONADO including 1300 diabetic patients with COVID, the authors find out that only BMI was a risk factor for intubation or death within 7 days: but not the age, not the level of glycaemic control, not the ACEi/ARB drugs...

2/ Oncology

During lockdown, there has been a huge drop for cancer screening tests (bowel, breast and cervix). It will be important to see the consequences of this drop in the future, especially for mammograms...

3/ Infectious diseases

A multicentric retrospective study looked at the risk of infection from using NSAIDs for anterior sinusitis in children. The authors found out that taking NSAIDs was associated with an increase in intracranial and orbital complications for 30 patients who took NSAIDs versus 90 patients who did not (80% vs 44% of adverse effects). It is only retrospective but this is another argument against NSAIDs in infections.

4/ Rheumatology

A lot of things have already been tested in knee osteoarthritis. This article from Annals of Family medicine studied the efficacy of intra-articular injections of hypertonic dextrose, as part of prolotherapy (an alternative therapy method which aims to make musculo-skeletal structures proliferate). The authors randomized 76 patients to receive dextrose injections or saline solution. After 1 year, patients who had dextrose injections had a lower WOMAC pain score (-10 points on a scale of 50) as well as a lower WOMAC function score (same magnitude of difference). There were also better scores for quality of life (studied by EQ5D) and no adverse event was recorded. Overall, we need to wait for more studies before rushing on this miracle treatment.

5/ The qualitative study by @Petronille

This week's article is a French paper that studies the impact of the first pelvic exam for French women between 18 and 30 years old, recruited from the surgery of a general practitioner. For these women, this exam is viewed as a rite of passage towards the adult age (to be noted: a good mother-daughter relationship could have a positive impact on this experience). The pelvic exam should follow a discussion between the doctor and the patient, should be quick, gentle and painless and be followed by a phase of reinsurance - the moments for discussion being experienced as very important. For the included women, the patient-centered approach was more important than the exam by itself: compliance with the will of the patient, quality of the relationship, inclusion of each patient's individuality. The authors offer a guide to improve the management of this first exam, possibly limited by the premises, but that makes think about this exam (and the others) offered at the surgery. This guide includes the relationship aspect, put forward on the agenda by the patients' study, contrary to the very technical guidelines by the CNGOF (NFrench National College of Gynaecologists and Obstetricians, link here in French).

That's all for this week. Do not forget to subscribe on Facebook, Twitter or to the newsletter by e-mail if it is not already done. You have to put your e-mail address at the top right of the page and confirm the subscription thanks to an e-mail labelled "FeedBurner Email subscriptions", that will be sent to you and may end up in your junk folder. 

I wish you very good week, full of rest, full of courage, full of sprinkles and joy in your life! Thanks for reading me each week!

@Dr_Agibus - free translation by @carttom

Dragi weekly No. 269 : Hypertension (2020 guidelines), COVID-19 (diagnostic tests, pregnancy guidelines RCGO, reusing masks), SGLT-2i

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 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).

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).

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.

It's over! Do not forget to subscribe on Facebook, Twitter or to the newsletter by e-mail if it is not already done. You have to put your e-mail address at the top right of the page and confirm the subscription thanks to an e-mail labelled "FeedBurner Email subscriptions", that will be sent to you and may end up in your junk folder. 
See you next week

@Dr_Agibus 
(free translation in English by @carttom)