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Hello, and welcome to this week’s Annals of Internal Medicine audio summary for our August 7, 2007 issue. I'm Michael Berkwits, Deputy Editor at Annals.
As usual, we have a great issue for you this week with articles on trends in mortality among men and women with diabetes; the prevalence of geriatric conditions in older adults, and their association with physical disability; and a review of changes in the most recent American Heart Association Basic Life and Advanced Cardiac Life Support guidelines.
Here’s an in-depth summary of those articles.
Our lead article this week documents trends in mortality among men and women with diabetes from 1971 to 2000.
An overall decline in US deaths from cardiovascular disease has been well-documented since the 1970s, but the only nationally representative study to look at mortality trends in patients with diabetes found no changes between 1971 and 1992.
In this week’s article, lead author Edward Gregg and his colleagues from the Centers for Disease Control and the NIH used national survey data to compare trends in all-cause and cardiovascular mortality rates among men and women with and without diabetes through the year 2000.
They found absolute declines in all-cause and cardiovascular morality in people with and without diabetes, but the decline was statistically significant only in the people without diabetes. More importantly, when they looked at men and women separately, they found that it was only the men who were dying less often. All-cause mortality for women with diabetes may actually have increased between 1971 and 2000; and while cardiovascular mortality declined for women without diabetes, it held steady in women with the disease.
The authors conclude from these data that women with diabetes are being left behind from trends leading to fewer deaths among men. They speculate that reasons for the disparity might include less aggressive risk factor control and medical management of acute ischemic events in women, and sex differences in the pathophysiology of coronary heart disease, including more complicated patterns of symptoms in women, and a greater tendency to have microvascular coronary heart disease.
They acknowledge that diabetes was ascertained by self-report, possibly leading to false negative reports by people who didn’t yet know they had disease. Sample sizes were relatively small, precluding a more thorough analysis of factors that could explain the trends. The authors don’t acknowledge that women with diabetes had higher mean body mass index at baseline, and greater increases in mean BMI over the years, compared to women without diabetes and men with and without diabetes. So differences in BMI, which the authors did not adjust for in their analyses, could explain some of the observed differences in this study.
Nevertheless, the authors conclude by pointing out that the advantage in survival that women typically have over men is nowhere to be found in women with diabetes. They express the hope that their findings could stimulate more research on why improvements in diabetes care and coronary risk factors have not translated to reduced mortality for women with diabetes, and more effective public health efforts to reduce the disparities.
With us today to discuss these findings is Dr. Nanette Wenger. Dr. Wenger is the Chief of Cardiology at Grady Memorial Hospital in Atlanta, and is a Professor of Medicine in the Division of Cardiology at Emory University. She is the author of numerous studies of heart disease and coronary risk factors in the elderly and women; was the senior author on the 2007 update of the American Heart Association’s evidence-based guidelines for cardiovascular disease prevention in women; and is the author of an Annals editorial accompanying this week’s lead article, entitled, “Heightened Cardiovascular Risk in Diabetic Women: Can The Tide Be Turned.”
Q: Dr. Wenger, thank you for joining us.
A: You’re quite welcome
Q: Is the increased risk in diabetic women observed in this study new or is it something that’s been observed before?
A: Well this is really a good question because it has been known for some time. In the 1970s and 1980s there is very good evidence that what we saw was cardiac mortality in the United State declining in nondiabetic men and women and in nondiabetic women. But, the mortality risk increased, as a matter of fact by 23%, in diabetic women. So this essentially is a continuation of that information and what we tend to see here is perhaps not as bad. Certainly the risk declined in diabetic and nondiabetic men and in nondiabetic women. But the benefit has not extended to the diabetic woman and that is really our concern. Why is it that diabetic women are doing not as well as the remainder of the population in terms of cardiac and cardiovascular mortality?
Q: And do we have preliminary answers to those questions? What might be the reasons for the difference?
A: There are probably a number of reasons. Some may be that we are not recognizing the diabetic woman as at increased risk and not instituting appropriate strategies. But there may be other reasons. It may be that the diabetic woman has as her problem not just diabetes but a clustering of risk factors and perhaps more severe risk factors or possibly even that diabetic women do not respond as well to some of the therapies that are instituted. But certainly what we have highlighted in this editorial is that we are seeing suboptimal care and in particular, control of abnormal lipid levels in the diabetic woman.
Q: In your opinion what role can an individual primary care provider plan in response to these differences?
A: In the editorial we’ve detailed data from managed care plans both commercial and Medicare plans showing that diabetic women are not optimally treated. As we all know diabetes is considered a coronary risk equivalent so that very precise control of LDL cholesterol is warranted. As a matter of fact, there was a very recent statement 2007 from the American Heart Association and the American Diabetes Association and what it did was highlight that treating diabetic patients with established coronary disease, lipid abnormalities, hypertension and hypercoagulability improved their event free survival and what this statement recommended was primary preventive strategies as well. The reason is that diabetic patients don’t die of their diabetes. 80% of them develop macrovascular disease and this is their major cause of death. So perhaps for the individual physician, what we have to do is as I said first to recognize that the diabetic woman is at excess coronary risk and secondly to take an aggressive and guideline based approach to coronary risk factor management.
Now this paper has highlighted that diabetic women in many of these settings were undertreated for LDL cholesterol abnormalities and probably even when treatment was instituted they were not titrated to goal and some other studies have shown that the diabetic woman and women in general may not get as many guideline-based therapies.
Q: So the point seems to be that woman don’t need to be more aggressively treated and controlled than men, but equally aggressively treated?
A: That’s really what we want is parity in therapy
Q: And finally the title of your editorial asks, “Can the tide of Heightened Cardiovascular Risk in Diabetic Women Be Turned? What’s your answer to that question?
A: My answer would be that I am cautiously optimistic. I expect that if we recognize that the diabetic woman is at increased risk, if she is educated that she is at increased risk and if our primary care providers and consultants aggressively investigate and manage risk characteristics and symptoms I would hope that the tide could be turned.
Q: Dr. Wenger, thank you so much for joining me.
A: You are quite welcome.
That was Dr. Nanette Wenger from Emory University in Atlanta commenting on the mortality disparities among diabetic men and women documented in this week’s lead Annals article.
Our second article this week, and the first of 2 CME articles in this issue, is a study of geriatric conditions in the elderly and the association of those conditions with disability. Lead author Christine Cigolle and her coauthors from the University of Michigan used national survey data from the year 2000 to assess the prevalence in the US of geriatric conditions in people over age 50. They measured 6 conditions, also commonly referred to as geriatric syndromes. These were cognitive impairment, falls causing injury, incontinence, low BMI, dizziness, and vision and hearing impairment. They found that almost half of US adults over age 50 have at least one of these conditions, and that in some cases, prevalence rates for the conditions were comparable to those of common chronic diseases.
They also measured disability, which they defined as dependency in bathing, dressing, eating, toileting, and transferring, and they found that the risk for disability was significantly increased in people with geriatric conditions, and that it commonly exceeded the risk of disability associated with heart and lung disease, diabetes, and cancer.
The authors acknowledge many limitations of their findings. The presence of geriatric conditions and disability were self-reported, and they did not measure delirium, another common condition in the elderly. The study was cross-sectional, so it could only measure association and not causality. And, there was almost certainly survivor bias affecting estimates of prevalence and risk for disability in the oldest adults in the study.
Nevertheless, the authors conclude that geriatric conditions such as incontinence and falling are at least as common as other chronic diseases that receive targeted attention in primary care visits, and that they are as or more strongly associated with disability. They make the additional point that geriatric conditions fall outside current models of health care which focus on discrete diseases, but that geriatric conditions are important to the health and function of older adults. Finally, they emphasize that patients and providers need an approach to care that facilitates the identification and management of these conditions.
Our other CME article this week is a review of Basic Life and Advanced Cardiac Life Support, with an emphasis on changes to the 2000 guidelines made in the 2005 American Heart Association guidelines for Cardiopulmonary Resuscitation.
Recommendations to call the emergency response system and give 2 rescue breaths followed by a carotid pulse check for at least 10 seconds remain the same. However the previous guidelines recommended a ratio of chest compressions to ventilation during CPR of 15:2 in patients without a pulse. The 2005 guidelines now recommend 30 compressions:2 ventilations, because 2 rescue breaths after every 15 compressions caused unacceptably long interruptions of 14 to 16 seconds, and were shown to reduce myocardial blood flow and 24 hour survival. The chest should be compressed at the center of the nipple line at a depth of 1.5 to 2 inches. Compressions should allow for complete recoil of the chest and should be performed at a rate of 100 per minute. Each breath should last 1 second.
The newer guidelines also distinguish between witnessed and unwitnessed cardiac arrest. Previously, immediate defibrillation was recommended whether or not the arrest was witnessed. The newer guidelines recommend an initial 2 minutes of CPR in unwitnessed arrest, a change that was based on studies suggesting that survival rates appear to be increased when CPR is delivered first, perhaps because CPR restores some perfusion to the heart, which improves the likelihood that it can respond to shocks
Previous guidelines called for 3 stacked shocks with pulse checks and rhythm analysis between shocks to assess for the return of spontaneous circulation. This approach was found to lead to long delays in CPR, and it is now better recognized that a perfusing rhythm rarely returns after a first shock. So the newer guidelines now recommend resumption of immediate CPR after a first shock for 5 cycles or about 2 minutes before rescuers recheck the rhythm and give a second shock.
Finally, the guidelines recommend 360 joules for the first and subsequent shocks when monophasic waveform defibrillators are used. Recommendations for biphasic waveform defibrillators depend on the device.
Listeners interested in the full guidelines can consult the December 13, 2005 supplement issue of Circulation, which is available online for free at circ.ahajournals.org, or just do a general Web search on “ACLS guidelines.”
Subscribers to Annals can receive CME credits by answering 2 quiz questions about this article and the one about geriatric conditions at cme.annals.org. Just click the "My CME" link, to register or sign in.
Other articles in this week’s issue include:
For full details of these and all articles, please consult your print journal, or go to www.annals.org.
That's it for today. Technical support for this summary was provided by Andrew Langman, Neil Kohl, and Beth Jenkinson.
Special thanks to Kevin Stahl and all our friends at WHYY, public radio and television of Philadelphia, who helped produce this podcast.
Send feedback, suggestions and comments about this audio summary and about Annals to podcast{at}acponline.org. Check back in 2 weeks for a complete summary of our regularly scheduled August 21, 2007 issue.
I’m Michael Berkwits, and thanks for listening.
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