TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.
This week’s topics include new hypertension guidelines, ongoing symptoms after mild or moderate COVID, a new medicine for people with severe kidney disease, and diabetes and risk of dementia.
Program notes:
0:45 Sequelae of mild or moderate COVID
1:46 Continuing care required
2:50 Cardiovascular issues
3:35 New hypertension guidelines
4:35 Awareness needed
5:32 May not have high blood pressure
6:32 Whether we’re effectively treated
7:15 New medicine for chronic kidney disease
8:18 Almost 8,000 patients, some on dialysis
9:05 Dementia and diabetes
10:05 Younger age at onset associated
11:05 Lots of possible mechanisms
12:45 End
Transcript:
Elizabeth Tracey: New hypertension guidelines.
Rick Lange, MD: A novel treatment of anemia in people with severe kidney disease.
Elizabeth: Does the age at which you develop diabetes affect whether you’re going to develop dementia?
Rick: And long-term follow-up of non-hospitalized COVID-infected patients.
Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, this week only talking about one study relative to COVID, so why don’t we start with that one, and that’s in the Morbidity and Mortality Weekly Report.
Rick: Which, obviously, is from the Centers for Disease Control (CDC) and Prevention. We spend a lot of time talking about COVID-infected patients and their hospitalized component, but of the over 22 million people that have contracted COVID here in the U.S., most have had either mild or moderate symptoms and most have not been hospitalized.
This was a joint study with the CDC and Kaiser Permanente in Georgia. They analyzed electronic health records of almost 3,200 non-hospitalized adults who had COVID-19. When they followed these for up to 6 months, approximately two-thirds of them had one or more outpatient visits during the follow-up, and during that time about two-thirds of them developed a new diagnosis.
Now, most of those were concentrated in the first couple of months, but 10% of those continued to need follow-up and have outpatient treatment for as long as 120 to 180 days afterward. The related symptoms included those that you might expect during COVID — things like shortness of breath and fatigue, muscle aches, headaches. It indicates that even in non-hospitalized patients they have continuing symptoms that require continuing care even months after they’ve recovered from infection.
Elizabeth: I noted that the majority of them, of course, were pulmonary in nature, but there were other things that were pretty prominent in these diagnoses subsequent to COVID infection.
Rick: You’re right. The new diagnosis included cough, shortness of breath, chest pain, throat pain, and fatigue. Those are the most common ones that people had follow-up for.
Elizabeth: Right. And they also had — a pretty significant number of them had cardiovascular issues.
Rick: So let’s distinguish that. Several of them had chest pain. Now, the chest pain may or may not be due to the cardiovascular issues. Even people that have had pneumonia, or inflammation of the lungs or lining of the lungs, or linings around the heart — that is pericarditis — can develop without frank cardiovascular disease. The severe cardiovascular disease, the myocarditis, the heart failure, fortunately, it’s relatively uncommon, but it can happen. It’s less than 1% of individuals.
Elizabeth: I think it’s really noteworthy that such a large number of people were still struggling with symptoms up to 6 months after they had been positively tested for COVID-19, and I guess I would ask you, if you were giving advice on this, what would you say to people who are still experiencing symptoms?
Rick: The first thing is obviously, be evaluated. Many of these symptoms will continue to be mild. They should qualify for an initial evaluation and then for people to realize these symptoms may not go away when the infection is clear. It may take weeks and months, and I’m going to take a step back. For those people that haven’t been vaccinated and think, “Oh, it’s going to be a mild disease because most people don’t get hospitalized,” well, that’s true. But two-thirds of these individuals still required follow-up for a new symptom they didn’t have before, so it’s not as benign, even in young individuals.
Elizabeth: Since we’re talking about cardiovascular disease, why don’t we turn to JAMA? The USPSTF, our favorite bunch of folks, has issued some new guidelines relative to screening for hypertension or high blood pressure. This is their update to their 2015 recommendations and they examined all the evidence again in the way that they always do.
Before we get into exactly specifically what they talk about, I was a little bit startled to see that 45% of the U.S. population actually has hypertension. 57% of non-Hispanic Black adults have hypertension, and we know what all the consequences of having uncontrolled hypertension are.
This control of blood pressure also, the editorialist reveals, has worsened over time. It’s decreased from 54% in 2013-2014 to 44% in 2017-2018, and who even knows how badly it might have deteriorated during the pandemic.
One of the things that they call for, of course, is awareness. In examining all of this evidence, they basically say, “Hey, anybody who is 18 years or older really ought to be assessed with an office blood pressure measurement.” Then they also recommend that some kind of a confirmation outside of the clinical setting for a diagnostic confirmation must be made before somebody is put on any treatment and that’s given an “A” recommendation. I think that’s really a good thing because we know so many people suffer from “white-coat hypertension.”
Rick: I agree with you on the importance of this. We’ve been talking a lot about COVID, with several hundred thousand people that have died in the U.S. as a result. Most of our listeners may not recognize that hypertension contributes to half a million deaths in the U.S. each year, and worldwide almost 8 million deaths, and obviously, you can’t treat if you don’t screen for it, and so screening early, and over the age of 40, it should be taken every single year.
As you mentioned, there is the white-coat syndrome, so people that may seem to have high blood pressure in the doctor’s office may not have it when they either have ambulatory blood pressures — that’s where someone wears a blood pressure machine for 12 to 24 hours and it takes the blood pressure every 20 to 30 minutes — or home blood pressure monitoring, and I use that in most of my patients now. I can manage their hypertension at home if, in fact, they have it.
Elizabeth: We also need to note that maybe you need to be screened more often if you’re in a risk group, and that includes obesity and other risk factors for having hypertension. Let me just ask you a question. You revealed that you tell your patients to go ahead and get one of these blood pressure monitors. Do they bring it in to have it calibrated in your office?
Rick: It’s a good point. I ask them to do that, Elizabeth. I ask them to bring it in so we’ll test it against ours. That way, I know that it’s accurate and they’re wearing one that fits on their arm, not on their fingers or on their wrist. You want one that fits on their arm, over their brachial artery, as these recommendations say.
Once we’ve confirmed that it works, I have them take it multiple times throughout the day over multiple weeks, and we use that to gauge whether they have hypertension or not, and secondly, whether we’re effectively treating it.
Elizabeth: I recently had a screening, just a regular old office visit, and in taking my blood pressure, I was not seated for 5 minutes previous to it, and I thought that was a lapse. We’ve also talked before about the need to take it bilaterally in order to get an accurate measurement.
Rick: Yes, and these are the things that should be done in a doctor’s office. But they’re hurried, people oftentimes aren’t trained to take blood pressure appropriately, and that’s why taking it at home provides a much more realistic picture of what the blood pressure is throughout the day. So, if your blood pressure’s normal in the doctor’s office, you’re fine. If it’s elevated, it needs to be confirmed and monitored in the home setting.
Elizabeth: Okay. Let’s turn to the New England Journal of Medicine, two of them, actually, that I gave to you with a very tongue-twisting name — and I’m famous, of course, for giving you those tongue-twisting names — for folks with kidney disease.
Rick: The tongue-twister is a medicine called vadadustat. It kind of has a nice ring to it. Here’s the background behind it. Most individuals that have kidney disease have anemia. The more severe the anemia, the worse their quality of life and the more complications the patients have. The common agents that we use to treat that are called erythropoiesis agents. These are growth factors that stimulate you to make red blood cells. But if you make too much, if you actually normalize the blood concentrations so they’re no longer anemic, it increases cardiovascular events.
By the way, these medications have to be given by injection. Well, recently, there was a Nobel Prize won for people that have looked at what’s called hypoxia-inducible factors, or HIF. Hypoxia means low oxygen. Low oxygen stimulates red blood cells. If you can increase HIF, you can increase red blood cells and that’s exactly what vadadustat does.
They looked at it in people that had severe kidney disease. There were almost 8,000 of these individuals — some on dialysis, some are not — and they showed two things. One is that it’s equivalent in terms of the current agents we have in terms of raising the blood count. However, it wasn’t nearly as safe in individuals that weren’t on dialysis as it was on individuals that were on dialysis. This is proof of concept. It’s a new agent and we need new agents. It’s an oral agent, which is great. It looks like it’s safest in those individuals who are on dialysis.
Elizabeth: So plus-minus, and so it sounds like risk-benefit analysis is appropriate here.
Rick: Yes, Ma’am, it does. Again, the nice thing, it’s an oral agent. Otherwise, it has very few side effects, so this will be one of many agents, I think, in this particular category.
Elizabeth: Let’s turn back, then, to JAMA, and this is an association study taking a look at age at diabetes onset and subsequent risk of dementia. As we know, the trends in type 2 diabetes internationally are showing that people are developing it all over the world at younger ages, and I have to say parenthetically, largely related to obesity, of course, and also changes in diet.
This gigantic study from the U.K. I thought was a really interesting study. They have just over 10,000 participants. They started them in 1985 to 1988. Since that time, they’ve had 1,710 cases of diabetes and 639 cases of dementia, with a median follow-up of just shy of 32 years.
Their dementia rates per 1,000 person years were 8.9 in participants without diabetes at age 70 years, and 10.0 per 1,000 person years for those with them, with the onset up to 5 years earlier, and there’s a linear relationship between how long you have it and how much more risk you have, with that number being 18.3 for those with more than 10 years of diabetes. So clearly showing that younger age at onset of diabetes is significantly associated with a higher risk of subsequent dementia and underpins for me this notion that I’ve had diabetologists say, that dementia is really a form of diabetes.
Rick: The other interesting thing about this is that late-onset diabetes was not associated with dementia, okay? It requires a certain period of time to have the diabetes, and you’re right, the longer you have it, the more likely you are to be affected. It increases the risk of dementia about 40% to 60%.
The unfortunate thing is we don’t really know exactly what the relationship is. The dementia associated with diabetes oftentimes doesn’t have the Tau proteins and the amyloid proteins that Alzheimer’s does, and there are a lot of different possible mechanisms. Is it because the sugar’s too high? Is it because the insulin’s too low? Is it because of oxidative stress?
But Elizabeth, your point is well-taken that the diabetes is increasing in frequency, it’s happening in younger individuals, and the longer you have it the more likely a person is to develop dementia over decades of life. Addressing this as a population, as a community, early on is incredibly important to prevent later complications.
Elizabeth: One thing I would like to note about this is this is the so-called Whitehall II study in the U.K. This was all government employees based in London and is largely comprised of Caucasians. They describe just how very few minorities are represented in the study, so I don’t think we really know the answer to that yet, or even really have that much data on if you’re African-American or Black or Hispanic — already with higher rates of diabetes — does that also put you at higher risk of dementia?
Rick: You’re right. As you noted, about 85% to 90% of these individuals, depending upon whether we look at the demented or non-demented population, in fact, were white. There were very few African-Americans and very few South Asians as well, although other studies have shown that risk factors in these individuals tend to exacerbate associated diseases — for example, hypertension, higher risk of stroke, higher risk of dementia, higher risk of cardiovascular complications — in these races and ethnicities. So I wouldn’t be surprised, even though this study doesn’t address it, whether we’d see the same thing in other minority populations.
Elizabeth: I would suspect the same. On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up, and make healthy choices.
Source: MedicalNewsToday.com
