Month: February 2021

Should I treat asymptomatic blood pressure (BP) elevation in my hospitalized patient with well-controlled BP prior to admission?

FA Manian MD, MPH, , , , , , , , , , Leave a comment

In contrast to the management of acute symptomatic hypertension in the hospital, evidence-based guidelines on when to treat asymptomatic BP elevation (eg, >160/90 mm Hg without signs of end-organ injury) in patients without acute conditions (eg, acute myocardial infarction [MI] or acute ischemic stroke) are lacking. The literature suggests, however, that a more permissive approach is appropriate in many asymptomatic patients with elevated BPs while hospitalized, particularly in those with well-controlled BPs as outpatient (1-4). 

In a 2018 study involving > 14,000 older adults hospitalized for common non-cardiac conditions, 52% of the cohort with elevated BPs (majority ranging ~160-180 mm Hg) but well-controlled BPs at home were discharged on a more intensive antihypertensive regimen (1). Patients with history of MI or cerebrovascular disease were no more likely and those with limited life expectancy, dementia or metastatic cancer were no less likely to receive antihypertensive intensification which suggests the decision for more aggressive treatment of elevated BP was in large part driven by the BP readings themselves. 

More intensive anti-hypertensive therapy has not only been associated with lack of reduction in cardiac events or improvement in BP control following discharge but also with more adverse events, such as acute kidney injury, MI, falls, syncope and hypotension and increased risk of readmission (2-3). 

Another concern is the frequent use of IV antihypertensives with its attendant risk of overcorrection and adverse events. One study found that about one-third of patients with asymptomatic uncontrolled BP treated with IV antihypertensives had an excessive drop in BP of more than 25% within 6 hours (5).

Since many factors may contribute to transiently elevated inpatient BPs (eg,  acute pain, stress, anxiety, exposure to new drugs and white coat hypertension) (1), the best advice when dealing with an elevated BP in hospitalized patients may be to repeat the BP, gather data on home BPs, contextualize the findings based on likelihood of benefits and risks of more intensive therapy and discuss with the outpatient provider before discharging patients on more intensified anti-hypertensive therapy (4). 

Bonus Pearl: Did you know that nearly one-half of patients with well controlled BPs at home have hypertension during their hospitalization? (1)

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References
1. Anderson TS, Wray CM, Jing B, et al. Intensification of older adults’ outpatient blood pressure treatment at hospital discharge: national retrospective cohort study. BMJ 2018;362:k3503. https://www.bmj.com/content/362/bmj.k3503

2. Anderson TS, Jing B, Auerback A, et al. Clinical outcomes after intensifying antihypertensive medication regimens among older adults at hospital discharge. JAMA Intern Med 2019;170:1528-36. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2747871

3. Rastogi R, Sheehan MM, Hu B, et al. Treatment and outcomes of inpatient hypertension among adults with noncardiac admissions. JAMA Intern Med. Published online December 28, 2020. https://acphospitalist.org/archives/2021/01/tailor-treatment-for-asymptomatic-inpatient-hypertension.htm

4. Kearney-Strouse J. Tailor treatment for asymptomatic inpatient hypertension. ACP Hospitalist 2021; 15:22-23. https://acphospitalist.org/archives/2021/01/tailor-treatment-for-asymptomatic-inpatient-hypertension.htm

5. Lipari M, Moser LR, Petrovitch EA, et al. As-needed intravenous antihypertensive therapy and blood pressure control. J Hosp Med 2016;11:193-198. https://onlinelibrary.wiley.com/doi/abs/10.1002/jhm.2510

6. Jacobs ZG, Najafi N, Fang MC, et al. Reducing unnecessary treatment of asymptomatic elevated blood pressure with intravenous medications on the general internal medicine wards: a quality improvement initiative. J Hosp Med 2019;14:144-150. https://pubmed.ncbi.nlm.nih.gov/30811319/

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

 

 

Should I treat asymptomatic blood pressure (BP) elevation in my hospitalized patient with well-controlled BP prior to admission?

What is the connection between anosmia, anasognosia and Alzheimer’s disease?

FA Manian MD, MPHLeave a comment

Both anosmia (loss of smell) and anosognosia (lack of awareness or insight of a deficit) appear to be strongly associated with higher risk of development of Alzheimer’s Disease (AD).1,2

In a study involving 90 patients with mild cognitive impairment (MCI) followed for up to 2 years, subjects with low olfaction scores were significantly more likely to develop AD than those with high scores (40% vs 0%, p<0.001).  In the same study, all patients with anosognosia (accounting for 84% of the low olfaction group) developed AD irrespective of higher baseline Mini Mental State Examination (MMSE) score. 1

A 2017 meta-analysis of olfactory dysfunction in MCI also found a significant association between olfactory deficits and MCI with tests of odor identification having larger effect sizes than those of odor detection threshold or memory.2

As for possible mechanisms, anosmia in AD is felt to be due to degeneration of neurons of the entorhinal- hippocampal-subicular complex associated with an observed increase in neurofibrillary tangles.3 Interestingly, the density of tau tangles in the entorhinal cortex have been shown to be inversely related to odor identification.4  There also seems to be a correlation between anosognosia and atrophy in the dorsal anterior cingulate cortex, reflected by the finding of hypometabolism on PET-FDG images6.

Bonus Pearl: Did you know that anosmia and ageusia (loss of sense of taste) are also common nonmotor feature of Parkinson’s Disease and can predate onset of motor symptoms by years? 5

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References

  1. Devanand DP, Michaels-Marston KD, Liu X, et al: Olfactory Deficits in Patients With Mild Cognitive Impairment Predict Alzheimer’s Disease at Follow-Up. Am J Psychiatry, 2000; 157:1399-405 https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.157.9.1399                                   
  2. Roalf DR, Moberg MJ, Turetsky BI, et al: A quantitavie meta-analysis of olfactory dysfunction in mild cognitive impairment. J Neurology Neurosurg Psychiatry 2017;88:226-232. https://jnnp.bmj.com/content/88/3/226
  3. Talamo BR, Rudel R, Kosik KS, et al: Pathological changes in olfactory neurons in patients with Alzheimer’s disease. Nature 1989; 337:736–739. https://doi.org/10.1038/337736a0 
  4. Wilson RS, Arnold, SE, Schneider JA, et al: The relationship between cerebral Alzheimer’s disease pathology and odour identification in old age. J Neurol Neurosurg Psychiatry, 2007;78:30-5. https://doi.org/10.1136/jnnp.2006.099721
  5. Tarakad A, Jankovic J: Anosmia and Ageusia in Parkinson’s Disease. International Review of Neurobiology, 2017; 133:541-556https://doi.org/10.1016/bs.irn.2017.05.028
  6. Guerrier L, Le Men J, Gain, A, et al: Involvement of the Cingulate Cortex in Anosognosia: A Multimodal Neuroimaging Study in Alzheimer’s Disease Patients. Journal of Alzheimer’s Disease 2018; 65:443-453. https://content.iospress.com/articles/journal-of-alzheimers-disease/jad180324

Contributed by Jackie Fairchild MD, Mercy Hospital-St. Louis, St. Louis, Missouri

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy, its affiliate healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

What is the connection between anosmia, anasognosia and Alzheimer’s disease?

Is Covid-19 vaccine effective in immunocompromised patients?

FA Manian MD, MPH, , , , , , , Leave a comment

The short answer is that we don’t have any solid data on the performance of Covid-19 among immunocompromised (IC) patients at this time because the large trials used to clear the available vaccines for FDA Emergency Use Authorization essentially excluded IC subjects (1,2). 

However, despite a potentially blunted response, the immunogenicity of the Covid-19 vaccine may be sufficient to reduce the risk of serious disease. The CDC and the American Society of Clinical Oncologists support Covid-19 vaccination of IC patients as long as there are no contraindications and patients are counseled about the uncertainty in vaccine efficacy and safety in this particular population (3,4).

 For patients undergoing treatment for cancer, the ASCO believes that Covid-19 vaccine may be offered in the absence of any contraindications.  To reduce the risk of Covid-19 while retaining vaccine efficacy, it recommends that the vaccine be given between cycles of therapy and after “appropriate waiting periods” for those receiving stem cell transplants and immunoglobulin therapy (4).

Previous experience with pneumococcal and influenza vaccine in IC patients have reported frequent suboptimal immunological response (2). Concomitant treatment with infliximab or other immunomodulatory drugs have had a negative impact on seroconversion after influenza vaccination. Similarly, in patients with Crohn’s on immunosuppressives, immune response to polysaccharide pneumococcal vaccine has been blunted (2). 

Nevertheless, the benefits of vaccination may still outweigh any risks of adverse events in this population. In fact, the CDC routine vaccination schedule for adults includes immunocompromised patients (5).  

At this time, given the seriousness of the Covid-19 pandemic and higher risk of severe disease among many IC patients, offering Covid-19 vaccine to these patients (with aforementioned caveats) seems prudent. 

 

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References

  1. Kumar A, Quraishi MN, Segal JP, et al. Covid-19 vaccinations in patients with inflammatory bowel disease. Lancet 2020;4:965-6. https://www.thelancet.com/journals/langas/article/PIIS2468-1253(20)30295-8/fulltext
  2. Polack FP, Thomas SJ, Ktichin N, et al. Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. N Engl J Med 2020;383:2603-15. https://www.nejm.org/doi/full/10.1056/NEJMoa2034577
  3. Interim clinical considerations for use of mRNA COVID-19 vaccines currently authorized in the United States. https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html. Accessed Feb 14, 2021.
  4. American Society of Clinical Oncologists. Covid-19 vaccine and patients with cancer.. https://www.asco.org/asco-coronavirus-resources/covid-19-patient-care-information/covid-19-vaccine-patients-cancer Accessed Feb 14, 2021
  5. CDC. Immunization schedules. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html Accessed Feb 14, 2021.  

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Is Covid-19 vaccine effective in immunocompromised patients?