Cardiovascular Medicine and Surgery
The Holy Grail of Blood Pressure Management?
Blood pressure treatment recommendations have been confusing over the past few years. The Joint National Committee (JNC) 8 stirred up controversy in 2014 because they raised the recommended tolerating systolic blood pressures, in certain people aged 60 and above, up to 150 mm Hg [James, et al. JAMA. 2014;311(5):507-520]. The new AHA/ACC hypertension guidelines cosponsored by 11 societies generated controversy because they changed the definition of hypertension (normal <120/80 mm Hg, elevated 120-129/80-89, stage 1 130-139/80-89, or stage 2 >140/90) [Whelton et al. J Am Coll Cardiol. 2017 pii:S0735-1097(17)41519-1]. The SPRINT trial [Wright, et al. N Engl J Med. 2015;373:2103-2116] largely influenced these recommendations. SPRINT demonstrated a 25% relative risk reduction of heart attack, stroke, cardiovascular death, or decompensated heart failure with more aggressive blood pressure management (BP goal <120/90 vs <140/90).
This new classification would label 46% of Americans, or 103.3 million people, as hypertensive. However, there is uncertainty in how broadly applicable the SPRINT results are, particularly in those under the age of 45. The majority of large clinical trials, including SPRINT, have limited numbers of patients who were less than 50 years old and, therefore, it is unknown if younger patients benefit to the same degree. The absolute improvement is also questionable because as an editorial points out [Welch, “Don’t Let New Blood Pressure Guidelines Raise Yours” NY Times. Nov. 15, 2017], the primary endpoint in SPRINT only occurred in less than or equal to 8% of patients.
These guidelines reinforce the need to measure ambulatory blood pressures, perform proper in-office blood pressure measurements, and emphasize lifestyle modifications. Whether aggressive blood pressure management is worth the potential risks and the degree to which ideal blood pressure measurement can be applied to real world practices, remains uncertain.
David J. Nagel, MD, PhD Steering Committee Member
Invasive fungal infections are frequently managed by ICU physicians and are a leading cause of mortality among critically ill patients. Invasive candidiasis is associated with an attributable mortality rate of up to 49%. Historically, the majority of these infections has been caused by Candida albicans, but this may be changing.
The first outbreak of Candida auris in the Americas (18 patients) occurred in the ICU of a hospital in Venezuela. Resistance to common azoles was documented, and half of the isolates showed decreased susceptibility to amphotericin B. As of August 2017, a total 153 clinical cases of C auris infection have been reported to CDC from 10 US states; most have occurred in New York and New Jersey.
What has been learned from these cases is that close contacts can be colonized, colonization can be persistent (approximately 9 months), the yeast can survive in the hospital environment, bleach or sporicide is needed for elimination, isolation precautions are recommended as for MDRO bacteria, and serial resistance to echinocandins has been observed.
1Candida auris isolates are often MDR, with some strains having elevated MICs to drugs in all the three major classes of antifungal medications.
2The isolates are difficult to identify and require specialized methods, such as MALDI-TOF or molecular identification based on sequencing.
3Misidentification may lead to inappropriate treatment.
4C auris has the propensity to cause outbreaks in health-care settings, as has been reported in several countries, and resistance may result in treatment failure.
Richard Winn, MD, MS, FCCPImmediate Past Chair
1. Sarma S. Current perspective on emergence, diagnosis and drug resistance in Candida auris. Infect Drug Resistance. 2017;10:155–165.
2. Pan American Health Organization/World Health Organization. Epidemiological Alert: Candida auris outbreaks in health care services. October 3, Washington, DC: PAHO/WHO; 2016.
3. Centers for Disease Control and Prevention. Global emergence of invasive infections caused by the multidrug-resistant yeast Candida auris. CDC; 2016 [updated June 24, 2016]