Clinical Challenge: Unexplained Tachycardia in 24-Year-Old Woman

Nonlaboratory Risk Factors Predict Adult Cardiovascular Events In Youth

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The following is a summary of "Predictors in Youth of Adult Cardiovascular Events," published in the October 2024 issue of Pediatrics by Nuotio et al.   

Childhood risk factors, including elevated blood pressure and obesity, are linked to adulthood cardiovascular disease (CVD) events.  

Researchers conducted a prospective study comparing the predictive utility of nonlaboratory risk factors and adolescent lipid levels for adulthood CVD events.  

They analyzed data from 11,550 participants (55.1% female, mean age 50.0 ± 7.7 years) from 7 longitudinal cohort studies in the United States, Australia, and Finland, focusing on adolescent risk factors including overweight or obesity, elevated blood pressure, smoking, and high borderline or high total cholesterol and triglycerides. The primary outcomes were fatal and nonfatal CVD events after age 25 (P<.05).  

The results showed that 513 participants (4.4%) had confirmed CVD events. Elevated blood pressure (HR 1.25 [1.03–1.52]), overweight (HR 1.76 [1.42–2.18]), obesity (HR 2.19 [1.62–2.98]), smoking (HR 1.63 [1.37–1.95]), and high total cholesterol (HR 1.79 [1.39–2.31]) independently predicted CVD events (P<.05). The addition of lipid measurements to the nonlaboratory model did not improve prediction (C-statistics for lipid model 0.75 [SD 0.07] and nonlaboratory model 0.75 [0.07], P=.82).  

They concluded that nonlaboratory risk factors and lipid levels measured during adolescence can independently predict adult CVD events, but adding lipids to the model does not enhance predictive capability.  

Source: publications.Aap.Org/pediatrics/article/doi/10.1542/peds.2024-066736/199627/Predictors-in-Youth-of-Adult-Cardiovascular-Events

Hypertension: New Guidelines And Classifications In Italy

Today in Italy, approximately 18 million people suffer from hypertension, many of whom are not perfectly controlled. According to the new guidelines, the number of citizens to be monitored rises to 25-28 million. Here are the new high blood pressure guidelines from the European Society of Cardiology (ESC). The National Congress of the Italian Society of Internal Medicine (Simi), currently taking place in Rimini, highlights the new blood pressure classification proposed by the European Society of Cardiology (ESC). In addition to high blood pressure values (above 140/90 mmHg) and normal values (below 120/70 mmHg), a new category emerges: those with 'elevated blood pressure,' with values between 120-139 mmHg systolic and 70-89 mmHg diastolic. Until 2018, the European guidelines on hypertension were shared by the ESC (European Society of Cardiology) and ESH (European Society of Hypertension), but now the two bodies have taken different paths. Giovambattista Desideri, secretary of Simi and professor of Internal Medicine and Geriatrics at Sapienza University of Rome, explains that 'by adopting the new classification of the European Society of Cardiology, the number of people to be monitored as hypertensive or with elevated blood pressure becomes much higher, more or less half of the entire population.' The data from the 'Heart Project' of the Istituto Superiore di Sanità, which indicate an average blood pressure of 132/77 mmHg for Italians between the ages of 35 and 74, fully fall into the category of 'elevated blood pressure.' Desideri clarifies that 'hypertension is never an 'on-off' phenomenon, but a biological parameter with a linear and continuous relationship with cardiac events,' emphasizing that the risk of heart attack or stroke does not simply disappear by falling below 140/90 mmHg. The three groups of the new classification are: those certainly to be treated (hypertensives, above 140/90 mmHg); those certainly not to be treated, but to be monitored over time (normotensives, below 120/70 mmHg); those to be monitored (group with elevated blood pressure) and possibly treated, evaluating individual characteristics case by case. If patients with elevated blood pressure have an increased cardiovascular risk profile, for example in the presence of diabetes, obesity, or kidney failure, 'then there is an indication for treatment, even if they do not fall into the category of hypertensives,' explains Desideri. The guidelines of the European Society of Hypertension (ESH), on the other hand, speak of 'high-normal blood pressure' or 'pre-hypertension,' for values of 130-139 mmHg systolic and 85-89 mmHg diastolic. Again, it is recommended to closely monitor these subjects and treat them based on cardiovascular risk. 'With the ESC 2024 guidelines, therefore, more than the concept, it is the 'wording' that changes to become more sensitizing,' Desideri specifies. The definition of 'elevated blood pressure' raises attention to people not yet frankly hypertensive, but who may need treatment based on their risk situation. Regarding therapeutic targets, the ESC suggests aiming for values between 120 and 129 mmHg, with a preference for the lower limit, especially for high-risk patients. However, Desideri emphasizes that 'in the case of the elderly or frail patient, greater caution is required,' applying the 'Alara' principle (As Low As Reasonably Achievable), meaning achieving the lowest possible value in relation to the patient's specific conditions. This personalization of treatment is central to the work of internists. On the type of treatment, ESC and ESH agree in recommending 'the use of pre-constituted combinations,' or pills containing two or three active ingredients, to simplify the patient's life and improve adherence to therapy. According to Giorgio Sesti, president of Simi, 'the greater emphasis placed by the new ESC guidelines on borderline blood pressure conditions fits into the vision that effective primary prevention must be able to identify and treat cardio-metabolic risk factors as early as possible with a global approach.' The internist, adds Sesti, is the most suitable figure to manage patients with multiple risk factors, assess signs of organ damage, and treat with personalized therapeutic strategies.

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The Importance Of Being -- Married

There are many good reasons to choose wisely and carefully when picking a spouse -- not the least of which is that you'll be spending an awful lot of time with them in both the near and distant future, possibly even raising children together.

So you want to find someone with whom you are compatible, share values -- someone who makes you happy. But perhaps one of the most compelling reasons to make an informed choice is that your spouse can affect your physical health in very direct, measurable ways.

"The choice of spouse is one of the most significant you'll make in your life; it is more serious than choosing a house or anything," says Brian Baker, a psychiatrist at the University of Toronto. "There is nothing like a good, solid marriage."

Baker should know: He has spent the past decade conducting studies that look at the effect of marital strain on cardiovascular health. In one of his most recent studies, he followed both men and women with borderline high blood pressure for three years and found that blood pressure is directly linked to what he calls "marital cohesion" -- how much couples do and share together.

"We found that if you had a bad marriage, it was best to avoid your spouse -- because if you are with your spouse, your blood pressure went up, and if you weren't with your spouse, your blood pressure went down," says Baker. "In a good marriage the opposite was the case."

An earlier study found that couples in good marriages had thinner heart walls than those in bad marriages. A thicker heart wall means higher blood pressure, "so that is an interesting finding," says Baker.

While the majority of studies so far have looked at cardiovascular effects, the plusses and minuses of marriage don't appear to be limited to that system.

In fact, they could be tied to how your body handles stress, says Baker, and the way that stress manifests itself could control the system most affected.

"It could be the immune system, or depression, gastrointestinal problems, rashes, or emotional disorders like anxiety conditions," he says.

Baker's research joins a small but growing number of studies pinpointing the varied health effects of marriage. One study, for example, showed that marital stress can double a person's risk of developing diabetes. Another study, out of Sweden, showed women in marital distress had a three times greater risk of a second heart attack. And a third showed that positive marital interactions can boost immunity and reduce the risk of heart disease by keeping stress hormones low.

"The benefits are better physical health, more resistance to infection, fewer infections, and a reduced likelihood of dying from cancer, from heart disease, from all major killers," psychologist and author John Gottman, PhD, tells WebMD. "The other health benefit is longevity: People live longer if they are in marital relationships, particularly if they are in good, satisfying relationships." Gottman, considered by many to be a pioneer in the field of marriage research, is the James Mifflin Professor in the department of psychology at the University of Washington in Seattle.

"There are physical benefits and mental health benefits," says Gottman. "You have less depression, less anxiety disorders, less psychosis, less posttraumatic stress disorders, fewer phobias. You also have fewer injuries due to accidents."

"The process gets reversed when relationships dissolve," he points out. This is especially true when one spouse dies. Oftentimes the surviving partner will die of what some call the "broken-heart syndrome."

"There is a bereavement process that is really well-documented," says Gottman. "People really go through [physical] grief and they secrete [the stress hormone] cortisol, and a lot of systems really shut down. [The grieving spouses] become more vulnerable to all kinds of infectious agents; their immune systems aren't working. So a person will get something like pneumonia and die very quickly. And they also lose the will to live."

In this scenario, men are more likely to be the one who dies of broken-heart syndrome, Gottman notes. But then again, men also typically reap the greater health benefits from being married while alive.

"If it is a good marriage, the benefits are equally as great for women as for men; for men, just being married confers a tremendous amount of benefits," Gottman says. "One of the major ways in which marriage confers effects is to reduce risk: Men stop engaging in risky behavior like bungee jumping and driving drunk. ... [They start] getting their health looked at on a regular basis and eating well. Single men really don't do that; they sort of fall apart.

"Women are less prone to risky behavior, more likely to go to doctor when they are sick, and they take care of themselves better," he says. "The other big, big difference is men have lousy social support systems, and women have great support systems."

This just goes to show you how much men get taken care of in a marriage, says David Woodsfellow, PhD, director of the Center for Relationship Therapy in Atlanta.

"While the traditional role has man as the provider, that role is really as the provider of money," he says. "In that traditional role ... The woman is the provider of nurturing comfort, home, and often food, clothing, and furnishings. I think it is those roles and their vestiges that account for the finding that marriage is better for men."

So being married can benefit your health. How can couples get the maximum benefit for both parties involved?

Woodsfellow offers these four tips for bridging the inevitable differences and keeping a marriage healthy and happy.

Talk to each other every day. "Make a point of learning what the other one's day was like," he says. "That becomes one type of quality time: undivided attention."

Say nice things to one another; give one another compliments. "Do this frequently," he says.

Try not to reject each other. "Be aware of the little moments when your partner is reaching out to you and try to respond to them rather than turn your back to them, even if you are busy," says Woodsfellow.

Develop your own little habits, rituals, secret words, or secret signals. "Little, special things become special bonds, special moments of intimacy," he says.

"That's one of the great things about love: When people really love and they make a commitment, they become enormously vulnerable and enormously powerful -- because they care so much and it connects them to the world in such a big way," says Gottman. "That's the amazing thing about all of these benefits: They are conferred by commitment. The commitment is like falling over backward and translates into making you a mensch and a concerned human being -- somebody who is involved in the community of mankind."

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