Association of 3 Different Antihypertensive Medications With Hip and Pelvic Fracture Risk in Older Adults - Review Dr Vivek Baliga

Dr Vivek Baliga, Consultant at Baliga Diagnostics discusses a recent paper.

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OBJECTIVE : To examine whether the use of thiazide diuretics for the treatment of hypertension is associated with reduced fracture risk compared with ACEI and CCB.

Methods:

• The study examined hip and pelvic fracture hospitalizations in ALLHAT participants (> 65 years & from USA only) randomized to chlorthalidone (CH), amlodipine besylate, or lisinopril from 1994 to 1998;
  
• The mean study follow-up was 4.9 years.
  
• Post-trial extended follow-up was conducted till 2006, using passive surveillance via national databases.
  
• MAIN OUTCOMES AND MEASURES Hip and pelvic fracture hospitalizations

 RESULTS:

• Total 22 180 participants (mean age, 70.4  years) were followed for up to 8 years (mean: 4.9  years) during masked therapy.
  
• After trial completion, 16 622 participants  were available were followed for up to 5 additional years (mean total follow-up: 7.8 years). 
  
• Participants in CH group had significantly lower risk of fracture by 21%  vs (amlodipine/lisinopril) on adjusted analyses [0.82 Vs 1.17 per 100 Person years ([HR], 0.79; P = 0.04).
  
• Risk of fracture was significantly lower by 25% in CH group vs lisinopril group (HR, 0.75; P = .04)
  
• No significantly difference in risk of fracture in CH Vs amlodipine group (HR, 0.82; ; P = .17).
• In extended follow-up, cumulative incidence of fractures was nonsignificantly lower in CH group vs (lisinopril or amlodipine) (HR, 0.87; P = .10) and vs each medication separately. 

CONCLUSION:

Elderly hypertensive patients on chlorthalidone (CH) therapy has lower risk of pelvic/hip fracture than those on ACE inhibitors in ALLHAT trial.   

Dr Vivek Baliga - PRECISION: Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis

Dr Vivek Baliga, Consultant at Baliga Diagnostics discusses a recent paper.

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OBJECTIVE: To assess cardiovascular, gastrointestinal, renal, and other outcomes with moderate dose celecoxib Vs ibuprofen and Naproxen in arthritis patients with high CV risk

METHODS:

• Patients who required NSAIDs for osteoarthritis or rheumatoid arthritis and were at increased CV risk were randomised to receive celecoxib, ibuprofen, or naproxen.
  
• Patients initially received celecoxib (100 mg BD), ibuprofen (600 mg TDS), or naproxen (375 mg BD) with matching placebo.
  
• Dosage can be increased upto: celecoxib -200 mg BD,  Ibuprofen 800 mg TDS, or  naproxen 500 mg BD for the treatment of symptoms
• Esomeprazole (20 to 40 mg) was provided to all patients for gastric protection.
• Low-dose aspirin (≤325 mg daily) was permitted to patients if required.
  
• Primary Composite Outcome :  Cardiovascular death (including hemorrhagic death), nonfatal myocardial infarction, or nonfatal stroke
• Analysis was done on both ITT (intention to treat) and on treatment population
  

Results

• Total 24081 patients were initially randomized,
  
• Baseline Characters:Mean Age 63 years, 23% patients had established CVD, 90% had osteoarthritis, 10% had rheumatoid arthritis
• Mean treatment duration: 20.3 months; Mean followup period of 34.1 months.
• During the trial, 68.8% of the patients stopped taking the study drug, and 27.4% of the patients discontinued follow-up
  
• No difference in primary end point between 3 drugs. Celecoxib was non-inferior to naproxen and ibuprofen in both ITT and on treatment analysis  (as shown in figure)

Conclusion:
At moderate doses, celecoxib was found to be noninferior to ibuprofen or naproxen with regard to cardiovascular safety

Link to the article
http://www.nejm.org/doi/full/10.1056/NEJMoa1611593

Dr Vivek Baliga - First Aid For Toothache

Tooth ache can be a nuisance. Here are some first aid tips from Dr Vivek Baliga to manage tooth ache at home.

Our oral cavity is a breeding ground for bacteria. Bacteria can increase the production of acid within the mouth, causing damage to the teeth and tooth decay. Tooth decay is a common cause of tooth ache.

Tooth ache usually starts slowly and can get worse over time. Patients describe it as a ‘throbbing’ or ‘aching’ pain or discomfort that is often worse at night. It may be a constant pain or one that comes and goes. The teeth become sensitive to hot and cold, meaning that eating or drinking hot or cold foods and fluids can make the pain worse.

Here are some simple tips to manage toothache.

1. Rinse the mouth with clean warm water. This can get rid of any large food particles that are stuck in between the teeth.

2. Clean the teeth and gums with dental floss to remove any small pieces of food stuck in the teeth.

3. Apply a numbing gel that contains a local anaesthetic to the area that is painful. Always seek medical advice before using any medication. Some local anaesthetic agents are harmful for children below the ages of 2 years.

4. Take painkillers if required. Simple paracetamol and ibuprofen can be sufficient.

Despite the above, tooth ache can continue sometimes. This could indicate more severe tooth damage than you thought or could be due to an underlying infection. In such situations, seeing a dentist as soon as possible is advised.

When to see a dentist  Persistent pain despite painkillers. Difficulty chewing and swallowing food. A high fever accompanies the toothache (could indicate a dental abscess). ·         The gums are swollen and red and there is pus formation. ·         If the patient develops difficulty breathing.

After-care

Once treated, make sure you maintain proper dental hygiene by flossing the teeth before brushing. Brush teeth twice a day with a good quality fluoridated toothpaste. Avoid smoking and chewing tobacco.

A word of caution

In older patients who have risk factors for heart disease, a toothache can sometimes be an indication of angina or a heart attack. Often patients have accompanying symptoms such as chest pain as well, and the pain is no worse on chewing and swallowing. If you have any concerns, talk to your doctor. 

Dr Vivek Baliga Presentation - Pulmonary Embolism

Dr Vivek Baliga, Consultant at Baliga Diagnostics discusses pulmonary embolism and how it should be managed in clinical practice.

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Pulmonary embolism - Diagnosis and management from Dr Vivek Baliga

Dr Vivek Baliga Health Check Before Taking Up Running

We recently conducted a blood pressure camp at a nearby gym, where all members who walked through the door had their blood pressure checked.

Of the 25 members we screened in 2 hours, we detected high blood pressure in 3 of them! One had a blood pressure of 220/130 mmHg (normal is around 120/80 mmHg), and he was just 37 years old! He had been working out without knowing he had high blood pressure, and it is likely that if you continued without treatment that he would be at risk of a heart attack, stroke or kidney disease.

Why get a medical check up?

The problem with illnesses such as high blood pressure and heart disease is that it can be ‘silent’. People are unaware they have a problem until they have undergone a health check-up. 

You may have heard of cases where young people have died suddenly when out for a walk or even when sitting at home. Many a time, these tragedies are due to undiagnosed heart disease which could have been detected if the person had undergone a medical check up.

What to get done

The important tests that must be done in all people looking to take up running as a hobby (or professionally) must include a blood test, electrocardiogram, echocardiogram and an exercise treadmill test.

Blood tests can help determine if an individual has low haemoglobin, high blood sugar and/or high lipids. All these can be risk factors for heart disease and can be easily treated though lifestyle modification and medicines.

An electrocardiogram (or ECG) is a test that looks at the electrical activity of the heart. An abnormality in the conduction of electricity is clearly seen on the ECG and this may need treatment. Rare cases that need immediate treatment have been picked up on an ECG and the information put together with other tests has helped reach a diagnosis. In some cases, the ECG can be normal even there is an underlying problem, though this is rare.

An echocardiogram is a specialised test where ultrasound waves are used to visualise the heart on a machine. The test will provide information on the structure of the heart muscle, the state of the valve and how strong the heart is pumping (called ejection fraction). Causes of sudden cardiac death such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy (ARVC) can be detected through this scan. Narrowing of the heart valves and abnormalities in their function such as leaks can also be detected easily. 

You can read about these conditions on the website www.heartsense.in.

An exercise treadmill test is a very useful test that can help determine how the heart performs when the person is exercising. The normal response is for the heart rate and blood pressure to go up and for the ECG to remain in normal limits. Exercise tests are doctor supervised and the patients are pushed till the heart rate reaches a particular value (called target heart rate, which is 220-age of the individual). Some tests are continued beyond the target heart rate, but this is rarely necessary.

The treadmill test can help determine the following – 

1. Is there any abnormality in the way the heart conducts electricity? This can be seen with the way the waves look, the regularity of the heart beating and the presence of extra beats or abnormal rhythms.

2. Is there any problem with the circulation of blood to the heart? This can be determined if there are changes in particular segments of the ECG on exercise or at rest.

If any abnormality is found, your doctor will let you know if you need any further investigations. Some patients may be advised not to exercise until all additional tests have been done.

While most patients who undergo these tests have normal results, it is not uncommon to pick up the odd case where the tests are positive. These patients have gone on to have either angioplasty, bypass surgery or have commenced medication. Lifestyle changes form part and parcel of these treatments as well, and must be followed strictly.

‘It is better to be safe than sorry’

 

You may have heard this before. It cannot be any further from the truth when it comes to running and your heart. These tests are simple to perform and take no more than a couple hours of your time. Numerous centres now offer these tests at a good price, with only a handful running specialist packages. 

Now that you have read this tip, make time to see your doctor and talk to them about getting the tests arranged. 

For more articles by Dr Vivek Baliga, click here.

Dr Vivek Baliga Presenation - Diastolic heart failure

In this presentation, Dr Vivek Baliga discusses a common cardiac problem encountered in clinical practice - Diastolic heart failure, a term now replaced by Heart Failure with Preserved ejection fraction.

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Dr Vivek Baliga - Diastolic heart failure - A complete overview from Dr Vivek Baliga

Dr Vivek Baliga - Getting Inspired For Running

Dr Vivek Baliga - How To Get Inspired For Running

Ask people who do not exercise every day what they think about running, and chances are they will retaliate with a comment ‘isn’t running boring?’

As a runner, it is possible to get easily offended by this comment; some may just sweep it under the rug and move on.

The fact of the matter is this – running is one of the most enjoyable sports there is. Furthermore, those who think that there is no fun in running may not realise that running forms the ‘building block’ of most sports. Cricketers run in between wickets and to bowl, footballers run, tennis players run; almost every ground sport has some form of running in it.

We have already talked about the ‘runner’s high’ in a previous section. This high aside, many runners find that running clears their head of stress and worries they may have had in the day. In the west, it is not uncommon to find people with busy jobs getting a run in even late in the night just to clear their head. 

At times, when running, it is not unusual to hit a ‘plateau’ – a phase where you just don’t feel like going for a run. This plateau can put a big dent in your running routine; many have even given up running due to this.

 

There is no shame in hitting a plateau – it is not a testament in any sense to being lazy or short of motivation. Every one hits it at some point in their running routine. It’s all about trying to come out of that phase and move on to the next level of running.

How can you achieve this? Well, get inspired! Here are some simple ways.

1

1. Remember why you took up running in the first place. It might have been to become fit because you were breathless when walking up stairs or because you looked at yourself in the mirror one day and did not like what you saw. 
2. Read an inspiring story – There are many runners who have been on a long and tedious journey to be a successful runner. Along the way, they have encountered many problems which most runners would anyway. Read about these and use their recommended strategies to restore your focus on your goals.
3. Set easy goals – Setting too many can confuse things for you. Decide on your goal and work towards it every day.
4. Play your favourite tunes before you run – If you love music, then playing tunes that inspire you are great before you head out for your run. Music can pump you up and get you prepared for your run.
5. Talk to a friend – There are friends who motivate, and these friends are invaluable when it comes to running. If you feel a lack of motivation, ask your friend or running buddy to give you a pep talk. All it takes sometimes is a little push to get you going again.
6. Attend local fun runs – If you are bored on a weekend and seek inspiration to run, just head out to any running events that may be going on in your neighborhood and cheer the runners. You don’t even have to run – just watching them can sometimes be inspiration enough. You will see people of different ages running, and these are an invaluable source of inspiration.
7. Reward yourself – If you have completed a run that you thought you could not do, then most certainly reward yourself once in a while. This could be in the form of eating a small portion of your favourite food, or enjoying a healthy dinner out with friends. We don’t recommend you buy yourself a Ferrari though. 
8. Have a blog – Having a running blog can be a great way to inspire yourself. When you don’t feel like going out for a run, just go through your own blog or the blog of others. Your mood reflects in your blog posts, and you will likely be reminded of how you felt when you ran and then came home to blog about it. 

Creating a blog is simple – you can do so on Blogger or Tumblr. Comments and congratulations from friends and even complete strangers can be a wonderful source of inspiration.