"The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure" provides a new guideline
for hypertension prevention and management. The following are the key messages(1) In persons older than 50 years, systolic blood pressure (BP) of
more than 140 mm Hg is a much more important cardiovascular disease
(CVD) risk factor than diastolic BP; (2) The risk of CVD, beginning at 115/75
mm Hg, doubles with each increment of 20/10 mm Hg; individuals who are normotensive
at 55 years of age have a 90% lifetime risk for developing hypertension; (3)
Individuals with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80
to 89 mm Hg should be considered as prehypertensive and require health-promoting
lifestyle modifications to prevent CVD; (4) Thiazide-type diuretics should
be used in drug treatment for most patients with uncomplicated hypertension,
either alone or combined with drugs from other classes. Certain high-risk
conditions are compelling indications for the initial use of other antihypertensive
drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor
blockers, β-blockers, calcium channel blockers); (5) Most patients with
hypertension will require 2 or more antihypertensive medications to achieve
goal BP (<140/90 mm Hg, or <130/80 mm Hg for patients with diabetes
or chronic kidney disease); (6) If BP is more than 20/10 mm Hg above goal
BP, consideration should be given to initiating therapy with 2 agents, 1 of
which usually should be a thiazide-type diuretic; and (7) The most effective
therapy prescribed by the most careful clinician will control hypertension
only if patients are motivated. Motivation improves when patients have positive
experiences with and trust in the clinician. Empathy builds trust and is a
potent motivator. Finally, in presenting these guidelines, the committee recognizes
that the responsible physician's judgment remains paramount.

https://jamanetwork.com/journals/jama/articlepdf/196589/JSC30096.pdf

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

https://caltcm.memberclicks.net/assets/documents/acc_aha_chf_2013_guidelines.pdf

2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

ACC/AHA
: American College of Cardiology/American Heart Association
ACCF/AHA
: American College of Cardiology Foundation/American Heart Association
ACE
: angiotensin-converting enzyme
ACEI
: angiotensin-converting enzyme inhibitor
ACS
: acute coronary syndrome
AF
: atrial fibrillation

/pdf/2016-esc-guidelines-for-the-diagnosis-and-treatment-of-acute-z18hg30pp1.pdf

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

We characterized the effects of ethanol on the activators of adenylate cyclase complex that act through the receptor site, the stimulatory guanine nucleotide-binding regulatory protein (Gs), or the catalytic unit. Ethanol had no effect on adenylate cyclase activity stimulated by Mn2+, a selective activator of the catalytic unit, whereas high concentrations of ethanol inhibited both basal and isoproterenol-stimulated adenylate cyclase. In contrast, in the presence of nonhydrolyzable GTP analogs, ethanol potentiated substantial increases in adenylate cyclase activity. In the presence of these GTP analogs, ethanol increased the Vmax without altering the affinity of adenylate cyclase for ATP. Ethanol also increased adenylate cyclase activity in membranes in which Gs had been preactivated with isoproterenol plus a nonhydrolyzable GTP analog, suggesting that ethanol enhanced the interaction between activated Gs and the catalytic unit. Paradoxically, the ability of cholera toxin and NAD+ to augment adenylate cyclase activity through an effect on Gs was attenuated by increasing concentrations of ethanol. These results suggest that acute exposure to ethanol has multiple effects on cardiac membrane adenylate cyclase.

Multiple effects of ethanol on cardiac adenylate cyclase.

Introduction: there is an important need for increased understanding of the pathophysiology of heart failure postinfarction, new treatment strategies, earlier implementation of effective strategies, and more effective use of existing therapies.

I n March 2010, the Congress of the United States passed the Health Care Reform Act and the accompanying Reconciliation Act and the President signed them into law. Th e most signifi cant social and fiscal legislation since the passage of civil rights legislation and the creation of Medicare during the Johnson administration, the health care reform legislation will decrease the large burden of uninsured by approximately 35 million and abrogate the ability of private insurance companies to refuse insurance because of preexisting conditions or rescind an individual’s insurance aft er the development of a new medical problem. It is likely that health care experts, political pundits, and the lay public will debate the merits of health care reform over the next decade: will individual states be able to effi ciently manage health insurance exchanges; will reform increase or decrease the federal defi cit; will patients who don’t receive their health care insurance from their employers buy insurance or will they fi nd it more cost effective to simply pay a fine; will safety net hospitals survive without the current levels of federal and state subsidies; will the current number of physicians and hospitals be overwhelmed by 35 million new insured patients; and will the middle class pay a disproportionate share of the total health care costs? Despite these points of disagreement one thing is clear—we will not be able to continue to deliver cost-eff ective and quality health care unless we are able to decrease overall health care costs. President Obama has reported and many experts agree that the most eff ective means of lowering health care costs over the next decade will be to eliminate “waste” in the health care system. As pointed out by Victor Fuchs, Professor of Economics and Health Research and Policy, Emeritus, at Stanford University, there are two possible defi nitions of waste (1) any intervention that has no possible benefi t for the patient or in which the potential risk to the patient outweighs any potential benefi t or “medical waste”; or (2) any intervention for which the value of the expected benefi t is less than the expected costs or “economic waste.” Medical waste occurs when a physician or caregiver does the wrong thing either because they are uninformed or are delivering care in an unethical manner. Fortunately, the incidence of medical waste is small. By contrast, economic waste is far more common and has been blamed at least in part on a fee-for-service reimbursement model that incentivizes physicians to do more—oft en without justifi cation—and a patient population that is highly demanding. For example, there are about three times as many magnetic resonance imaging scans performed each year in the US as there are in Canada; however, the increased number of scans does not translate into improved care. In many cases, economic waste does not occur because physicians are incentivized to overuse tests and devices but because there is little or no information that allows them to make sound judgments regarding the choice between diff ering treatment strategies. Without scientifi c documentation, it also becomes problematic for regulatory bodies to recommend or mandate one treatment option as opposed to a second and potentially more expensive option. Th is equipoise is important because newer treatments are oft en—but not always—more expensive than older therapies. Examples of these cost-related decisions abound; the use of bare-metal stents versus the more expensive drug eluting stents in patients with coronary artery disease; traditional open surgery versus robotic surgery for the treatment of prostate cancer; and the use of expensive new generation antibiotics versus older generic medications for the treatment of communityacquired infections. Similarly, studies have not defi nitively assessed the benefi ts aff orded by many screening tests for disease prevention or to improve survival by earlier detection—the controversy regarding the use of mammography to detect early breast cancer being a good example. Research initiatives in “comparative eff ectiveness” will focus on addressing these important questions and the health care reform legislation provides funding for such studies. Indeed, the Institute of Medicine has provided a list of the 100 top topics for early intervention. It is in this knowledge gap that the clinical and translational sciences can play a signifi cant role. The “science” that will inform health care reform fits well within the sphere of translational research as it spans the continuum of bench research, clinical research, and population health. Indeed, the rapid translation of new discoveries from the bench to the community setting is a fundamental goal of translational medicine. In addition, investigators in Clinical and Translational Science Award (CTSA) centers routinely carry out studies that compare various drugs and devices as well as surgical or interventional approaches while also performing population and community-based studies to assess the effects of new methods of health care delivery on costs and quality of care—the results of which are essential in understanding and eliminating Health Care Reform and Translational Medicine

https://ascpt.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1752-8062.2010.00195.x

Arthur M. Feldman

Papers

Multiple effects of ethanol on cardiac adenylate cyclase.

Introduction: there is an important need for increased understanding of the pathophysiology of heart failure postinfarction, new treatment strategies, earlier implementation of effective strategies, and more effective use of existing therapies.

Health Care Reform and Translational Medicine

The Heart Failure Society of America in 2020: a vision for the future.

Working group 1: How to increase the output of cardiologists