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Phenomenon: Little is known about how participation in disaster relief impacts medical students. During the terror attacks of September 11, 2001, New York Medical College School of Medicine students witnessed the attacks and then became members of emergency treatment teams at St. Vincent's Hospital, the trauma center nearest to the World Trade Center. To date, only two reports describe how 9/11 influenced the lives of medical students. This study was designed to characterize the short- and long-term effects on NYMC students and to compare those effects between students assigned to St Vincent's Hospital and classmates assigned to rotations at facilities more remote from the attack site. We hypothesized that participation in direct relief efforts by students assigned to the St. Vincent's site might have long-lasting effects on their lives and these effects might vary when compared to classmates assigned elsewhere. Approach: This was a retrospective, survey-based, unmatched cohort study. Participants included all school of medicine graduates who were St. Vincent's rotators on 9/11 (N = 22) and classmates (N = 24) assigned to other sites who could be contacted and agreed to participate. Our primary measure was whether the 9/11 experience affected the participant's life, defined as an affirmative response to the item which asked whether the 9/11 experience affected the participant's "life thereafter, career choice, attitudes toward life or attitudes toward practice." Secondary measures included self-reported effects on career, life, attitudes, health, resilience, personal growth, personality features, and the temporal relationship between the attack and stress symptoms. Findings: Completed surveys were received from 16/22 (73%) St. Vincent's and 18/24 (75%) non-Saint Vincent's participants: 62% male, 82% had children, 74% identified as Caucasian/white and 76% employed full-time. Overall, slightly more than half (58%) of respondents reported an effect of 9/11 on their life, with a greater but non-significant proportion of St. Vincent's rotators reporting life impact (67% versus 50% for St. Vincent's versus other locations, respectively). High post-9/11 stress levels, current marriage, and ability to make and keep family and social relationships were associated with an effect on life which approached statistical significance. Participants reported positive or no post 9/11 effects on empathy and altruism (50%), resilience (47%), attitudes toward medical practice and career (32%), and charitable giving (24%), while positive, negative, or no effects were reported for attitude toward life, family and social relations, physical health, and conscientiousness. Mental health was the only domain in which all participants reported unchanged or negative effects. Two St. Vincent's rotators but no students assigned elsewhere believed they experienced 9/11-related post-traumatic stress disorder. Insights: Just over half of New York Medical College School of Medicine students rotating at St. Vincent's Hospital on 9/11 or elsewhere reported significant life-effects as a result of direct/indirect experiences related to the attack. Perceived stress may have been a more important driver of this life-change than other factors such as geographic proximity to the disaster site and/or direct participation in relief efforts. Further study of medical school interventions focused on stress reduction among students who participate in disaster relief is warranted. [ABSTRACT FROM AUTHOR]

The 2017 American College of Cardiology/American Heart Association hypertension guidelines diagnose hypertension if systolic blood pressure (SBP) is ≥ 130 mmHg or diastolic blood pressure (DBP) is ≥ 80 mmHg. Increased BP is SBP 120-129 mmHg with DBP < 80 mmHg. Lifestyle measures should be used to treat individuals with increased BP. Lifestyle measures plus BP-lowering drugs should be used for secondary prevention of recurrent cardiovascular events in individuals with clinical cardiovascular disease (coronary heart disease, congestive heart failure, or stroke) and an average SBP ≥ 130 mmHg or an average DBP ≥ 80 mmHg. Lifestyle measures plus BP-lowering drugs should be used for primary prevention of cardiovascular disease in individuals with an estimated 10-year risk of atherosclerotic cardiovascular disease (ASCVD) ≥ 10% and an average SBP ≥ 130 mmHg or an average DBP ≥ 80 mmHg. Lifestyle measures plus BP-lowering drugs should be used for primary prevention of cardiovascular disease in individuals with an estimated 10-year risk of ASCVD < 10% and an average SBP ≥ 140 mmHg or an average DBP ≥ 90 mmHg. White coat hypertension must be excluded before starting antihypertensive drug treatment in individuals with hypertension with a low risk for ASCVD. BP should be lowered to < 130/80 mmHg in patients with coronary heart disease, heart failure, or chronic kidney disease; after renal transplantation; for secondary stroke prevention; in lacunar stroke, peripheral arterial disease, and diabetes mellitus; and in ambulatory community-dwelling adults aged > 65 years. The selection of antihypertensive drug treatment is discussed. [ABSTRACT FROM AUTHOR]

For centuries there has been an ongoing search to identify the secrets of long life and healthy aging. Recently, multiple factors have been identified, including genetics, the introduction of antibiotics, vaccines, and public health, effective management of cardiovascular risk factors, advances in surgery, eliminating or modifying high-risk behaviors, family and social supports, eliminating wars and poverty, luck, exercise and nutrition, and psychological factors such as optimism and conscientiousness. To increase a maximum life span now estimated to be 115-120 years will involve manipulation of genes and the body's stem cells and the potential use of senolytic drugs (that kill old cells), which will need to be investigated. This is a worthy pursuit if these interventions will also maintain or enhance quality of life. [ABSTRACT FROM AUTHOR]

Apparent treatment-resistant hypertension (aTRH) is defined as blood pressure (BP) >140/90 mmHg despite three different antihypertensive drugs including a diuretic. aTRH is associated with an increased risk of cardiovascular events, including stroke, chronic renal failure, myocardial infarction, congestive heart failure, aortic aneurysm, atrial fibrillation, and sudden death. Preliminary studies of renal nerve ablation as a therapy to control aTRH were encouraging. However, these results were not confirmed by the Symplicity 3 trial. Therefore, attention has refocused on drug therapy. Secondary forms of hypertension and associated conditions such as obesity, sleep apnea, and primary aldosteronism are common in patients with aTRH. The pivotal role of aldosterone in the pathogenesis of aTRH in many cases is well recognized. For patients with aTRH, the Joint National Committee-8, the European Society of Hypertension, and a recent consensus conference recommend that a diuretic, ACE inhibitor, or angiotensin receptor blocker and calcium channel blocker combination be used to maximally tolerated doses before starting a 'fourth-line' drug such as a mineralocorticoid receptor (MR) antagonist. Although the best fourth-line drug for aTRH has not been extensively investigated, a number of studies summarized here show that an MR antagonist is effective in reducing BP when added to the standard multi-drug regimen. [ABSTRACT FROM AUTHOR]

J Clin Hypertens (Greenwich). 2011;13:649-653. ©2011 Wiley Periodicals, Inc. Key Points and Practical Recommendations [ABSTRACT FROM AUTHOR]

The article reports on the use of Angiotensin receptor blockers (ARBs) in managing hypertension. It states that ARBs are able to interrupt rennin-angiotensin-aldosterone system (RAAS) overactivity and its pathogenic properties causing hypertension. It also cites a research in which intake of ARBs such as losartan and valsartan for 12 weeks is proven to reduce systolic and diastolic blood pressure. Moreover, it concludes that ARBs serve as important treatment means for hypertensive patients.

Calcium channel blockers (CCBs) share a common mechanism of action. However, the manner in which they exert their pharmacological effects is different between subclasses. Dihydropyridine (DHP) CCBs tend to be more potent vasodilators than non-dihydropyridine (non-DHP) agents, whereas the latter have more marked negative inotropic effects. Both subclasses have a similar capacity to lower BP; however, non-DHPs appear to offer potential advantages in the management of patients with chronic kidney disease and diabetic nephropathy. Representatives of both classes are now available in fixed-dose combinations containing an ACE inhibitor, the benefits of which include effective 24-hour BP control, a reduced incidence of adverse effects, and improved adherence. [ABSTRACT FROM AUTHOR]

The introduction of β-adrenergic-blocking drugs into clinical medicine in the early 1960s represented a major advance in pharmacotherapy. The use of these drugs highlighted the importance of the sympathetic nervous system in contributing to the pathophysiology of a wide variety of cardiovascular and noncardiovascular disorders. This article summarizes the history of β-blocking agents and reviews the applications of this therapeutic class. These drugs may be useful as primary protection against cardiovascular morbidity and mortality in hypertensive patients and have proved to be beneficial in other cardiovascular conditions. Not all β-blockers have the same mechanism of action and, among them, there are pharmacologic differences that may be of clinical importance. [ABSTRACT FROM AUTHOR]

The superior diastolic blood pressure reduction (BP) of high-dose combination therapy with trandolapril (Tr) and verapamil-SR (Ve) compared with monotherapy has previously been reported. Guideline changes, placing greater emphasis on systolic BP, prompted a re-evaluation of TV-51 and an assessment of a subset of patients from the INternational VErapamil-SR Trandolapril STudy (INVEST). The objective of this analysis was to determine if the short-term antihypertensive effects of high-dose Tr+Ve (Tr/Ve study) could be confirmed in a sample of higher-risk INVEST patients with longer follow-up. The Tr/Ve study was a double-blind, randomized, parallel-group, placebo-controlled trial to evaluate the antihypertensive effects of trandolapril and verapamil-SR alone or in combination in 631 patients randomized to placebo, 4 mg trandolapril, 240 mg verapamil-SR or 4mg/240mg Tr+Ve combination for 6 weeks; 581 INVEST patients were selected for comparison with 24-month BP data, 90% use of trandolapril and verapamil-SR combination therapy and no triple therapy. Tr+Ve combination treatment achieved significantly greater systolic and diastolic BP reduction versus monotherapy. The BP-lowering effects of high-dose Tr+Ve achieved during short-term treatment were confirmed in INVEST during longer follow-up. Despite differences in the risk profiles of previously studied patients and INVEST patients, the antihypertensive effects of Ve+Tr were similar. [ABSTRACT FROM AUTHOR]

Beta-adrenergic blockade has provided one of the major pharmacotherapeutic advances of the 20th century. Beta-blockers are first-line drugs for the management of systemic hypertension, used alone and in combination with other antihypertensive agents. Drugs in the beta-blocking class have the common property of blocking the binding of catecholamines to beta-adrenergic receptor sites; however, there are significant pharmacodynamic and pharmacokinetic differences between the individual agents that are of clinical importance. Among these differences are the completeness of gastrointestinal absorption, the degree of hepatic first-pass metabolism, lipid solubility, protein binding, brain penetration, concentration within the cardiac tissue, rate of hepatic biotransformation, and renal clearance of drug and/or metabolites. Long-acting formulations of existing beta-blockers are currently in use, and ultra-short-acting agents are also available. Age, race, cigarette smoking and concomitant drug therapy can also influence the pharmacokinetics of beta-blocking drugs. The wide interpatient variability in plasma drug concentrations observed with beta-blockers makes this parameter unreliable in routine patient management. Despite the pharmacokinetic differences among beta-blockers, these drugs should always be titrated to achieve the desired individual patient response. [ABSTRACT FROM AUTHOR]

Compares the effects of anti-arrhythmic agents verapamil with amlodopine and amlodipine plus atenolol on exercise performance and ambulatory ischemia in patients with chronic stable angina pectoris. Exercise tolerance testing results; Cumulative ischemic duration at baseline from electrocardiograph monitoring for patients with baseline ischemic events.

Isolated systolic hypertension (ISH) is a common disorder in the elderly, carrying with it a high risk of cardiovascular morbidity and mortality. Environmental and age-related factors believed to contribute to ISH include obesity, declining physical activity, stress, and such dietary changes as increased salt intake and decreased intake of calcium and potassium. Increased rigidity of the aorta resulting in reduced compliance is an important hemodynamic feature, but factors that increase peripheral resistance also appear to play a role. Antihypertensive drugs have been shown to effectively and safely lower the systolic blood pressure elevations characteristic of ISH. To date, use of low drug doses and careful titration of dosage have avoided significant orthostatic hypotension and undue lowering of the diastolic pressure. Studies of relatively small groups of patients suggest that antihypertensive drugs can lower the risk of cardiovascular morbidity/mortality associated with ISH but the definitive answer awaits results of the ongoing large-scale Systolic Hypertension in the Elderly Program trial. In the interim, management should begin with conservative measures such as weight loss, salt restriction and, possibly, calcium supplementation. If this fails, drug therapy should be considered in patients with systolic blood pressures above 180 mm Hg and in those with systolic readings between 160 and 180 mm Hg who have concomitant cardiovascular risk factors. To date, no controlled trials of sufficient size have demonstrated that one drug class is more effective than another in treating ISH. Drug therapy should be tailored to the individual patient, starting with a low dose of a single drug and, if necessary, slowly increasing dosage until a systolic blood pressure under 160 mm Hg is attained. [ABSTRACT FROM AUTHOR]

Presents the keynote address delivered at the 40th Annual Alpha Omega Alpha induction ceremonies at Albert Einstein College of Medicine in New York, New York. Qualities that every medical student must have in order to become a physician; Obstacles facing physicians; Ways to combat clinical dogmatism.

Epidemiologic data obtained over the past 30 years suggest that a number of new biologic markers are associated with increased risk for cardiovascular disease. These include indices related to (1) altered glucose metabolism, particularly insulin resistance; (2) hyperlipidemia; (3) elevated levels of lipoprotein(a) and homocysteine; (4) increased levels of molecules reflecting decreased fibrinolysis and increased activation of the coagulation cascade; (5) elevations in cell adhesion molecules and other markers of endothelial function; and (6) elevations in molecules associated with infection, inflammation, and vascular remodeling. Changes in molecules associated with increased risk usually occur in clusters. This clustering suggests that effective treatment of one marker may have positive effects on multiple markers. Indeed, several studies have demonstrated that therapies designed to reduce hyperlipidemia may also lower the plasma levels of factors associated with increased coagulation and reduced fibrinolysis. Thus, careful assessment of patient risk factors, and the development of therapies directed toward chains of markers associated with increased risk, may significantly alter the course of cardiovascular disease. [ABSTRACT FROM AUTHOR]

Investigates the effectiveness of calcium antagonists as treatment options for patients with ischemic heart disease and systemic hypertension. Role of calcium antagonists in cardiovascular disease; Risks of calcium antagonists as monotherapy; Negative inotropic effect of first-generation calcium antagonists.

The article describes the physiologic effects of laughter and discusses the implications of humor and laughter on cardiovascular health. According to the author, good stress such as laughter may have beneficial effects on the cardiovascular system. Neuroendocrine effects, cardiovascular effects and clinical implications of laughter are presented.

Focuses on the use of the Antihypertensive and Lipid-lowering Treatment to Prevent Heart Attack Trial (ALLHAT) for preventing myocardial infarction. Allocation of the ALLHAT participants in a double-blind manner; Reduction of the cardiovascular risk at a commensurate degree; Use of alpha-Blockers as an add-on therapy in treatment-resistant patients.

Discusses the drug carvedilol. Nature of the drug; Approval for essential hypertension and symptomatic heart failure; Pharmacodynamic and pharmacokinetic properties; Clinical effectiveness for congestive heart failure, hypertension, and ischemic heart disease; Clinical use in heart failure; Side effects; Conclusions.

There is a paucity of information regarding how cardiovascular risk factors (RF) modulate the impact of diabetes mellitus (DM) on the heart failure hospitalization (HFH) risk following an acute myocardial infarction (AMI). Adult survivors of an AMI were retrospectively identified from the 2014 US Nationwide Readmissions Database. The impact of DM on the risk for a 6-month HFH was studied in subgroups of RFs using multivariable logistic regression to adjust for baseline risk differences. Individual interactions of DM with RFs were tested. Of 237,549 AMI survivors, 37.2% patients had DM. Primary outcome occurred in 12,934 patients (5.4%), at a 106% higher rate in DM patients (7.9% vs 4.0%, p < 0.001), which was attenuated to a 45% higher adjusted risk. Higher HFH risk in DM patients was consistent across subgroups and significant interactions were present between DM and other RFs. The increased HFH risk with DM was more pronounced in patients without certain HF RFs compared with those with these RFs [age < 65: OR for DM 1.84 (1.58–2.13) vs age ≥ 65: OR 1.34 (1.24–1.45); HF absent during index AMI: OR for DM 1.87 (1.66–2.10) vs HF present: OR 1.24 (1.14–1.34); atrial fibrillation absent: OR for DM 1.57 (1.46–1.68) vs present: OR 1.19 (1.06–1.33); P interaction < 0.001 for all]. Similar results were noted for hypertension and chronic kidney disease. AMI survivors with DM had a higher risk of 6-month HFHs. The impact of DM on the increased HFH risk was more pronounced in patients without certain RFs suggesting that more aggressive preventive strategies related to DM and HF are needed in these subgroups to prevent or delay the onset of HFHs. • Patients with diabetes mellitus were more likely to have adverse heart failure-related outcomes in the subsequent 6 months following an acute myocardial infarction. • Higher heart failure admission risk with diabetes was consistent across subgroups of age and major cardiac risk factors. • The impact of diabetes on post-myocardial infarction heart failure admission risk was higher in patients without certain important heart failure risk factors. • Understanding the differential impact of diabetes mellitus on heart failure risk among clinically relevant subgroups should prompt investigations of strategies to mitigate or delay the HF risk. • Patient groups with higher heart failure risk attribution from diabetes might benefit from aggressive therapy and follow up to delay the onset of heart failure requiring hospitalization. [ABSTRACT FROM AUTHOR]