Latest / Morning Medical with Dr. Chow / New ESC Guidelines, Hypertension Updates, and Innovations in Respiratory Health

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New ESC Guidelines, Hypertension Updates, and Innovations in Respiratory Health · Morning Medical with Dr. Chow

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Good morning and welcome to another episode of Morning Medical with Dr.
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Chow.
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I'm your host, Dr.
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Chi-Ming Chow, and today we're diving into some significant updates in the world of cardiology.
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The European Society of Cardiology, or ESC, has just released a streamlined set of guidelines
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covering a range of cardiovascular conditions, including atrial fibrillation, chronic coronary
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disease, peripheral artery disease, aortic disease, and hypertension.
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These updates have been designed with an emphasis on shared decision-making and
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implementation.
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Let's break down these changes and what they mean for both clinicians and patients.
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First, let's talk about chronic coronary syndromes.
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The new guidelines introduce a fresh definition for these syndromes, moving away from the
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traditional view of stenosis causing myocardial ischemia.
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Instead, the focus is now on a more dynamic concept of coronary microvascular dysfunction.
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This dysfunction, along with stenosis in the epicardial coronary artery and vasomotor
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disturbances, leads to the development of myocardial ischemia and chronic coronary
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syndromes.
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This shift in understanding is crucial because it acknowledges that these mechanisms can be
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present in every patient we see.
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One of the significant changes in the diagnosis recommendations is the introduction of a new
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risk factor-weighted likelihood model for the pretest probability of obstructive coronary
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artery disease.
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This model replaces the previous one that often overestimated risk, thereby avoiding
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unnecessary additional testing for many patients.
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Additionally, exercise testing is now recommended solely for assessing prognosis and
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adjusting likelihood, rather than for diagnosis.
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The guidelines also bring new class 1 recommendations, particularly with regard to
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intravascular imaging and physiology.
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These are seen as long-overdue changes.
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For instance, in the United States, guidelines still do not have class 1 recommendations for
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these areas, but hopefully, that will change soon.
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For patients without obstructive disease, the guidelines now suggest considering angina or
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ischemia with non-obstructive coronary arteries.
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When it comes to antithrombotic therapy, the guidelines have been updated to allow for the
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combination of aspirin and a strong P2Y 12 inhibitor in specific high-thrombotic-risk
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conditions, such as left main bifurcation and chronic total occlusion.
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Clopidogrel can now be used as an alternative to aspirin in long-term single-antiplatelet
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therapy.
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The guidelines also recommend the use of aspirin in patients with significant coronary
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artery disease, even if they do not have a prior history of myocardial infarction.
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Additionally, there is a stronger recommendation for short dual-antiplatelet
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therapy in patients with a high bleeding risk.
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The guidelines also address residual risk by pointing to GLP-1 drugs for patients with
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obesity and colchicine for reducing inflammation.
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These updates are seen as exciting changes that could significantly impact patient care.
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Moving on to atrial fibrillation, or Afib, the new guidelines emphasize an integrated approach
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to care.
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This starts with treating comorbidities and risk factors in paroxysmal cases before
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focusing on stroke risk reduction.
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The CHA 2 DS 2 -VASc score is now recommended as a simplified tool for selecting patients for
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anticoagulation for stroke risk reduction, and the use of a bleeding risk score to start or
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withdraw anticoagulation is no longer recommended.
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In terms of treatment, ablation is now considered first-line therapy for paroxysmal
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Afib, and endoscopic or hybrid treatment has a class IIa recommendation for persistent Afib
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despite the use of antiarrhythmic drugs.
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The guidelines also emphasize the importance of dynamically reassessing patients to see how
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their Afib and comorbidities are evolving.
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For example, putting a direct oral anticoagulant back to full dose after acute
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kidney injury has resolved is now recommended.
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For the first time, the ESC has combined guidelines for peripheral artery disease and
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aortic diseases to highlight that these conditions are part of one unique vascular
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system.
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This combination underscores the importance of globally assessing patients since these
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diseases share common risk factors and management strategies.
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The guidelines simplify the classification of peripheral artery disease into three clinical
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presentation groups: asymptomatic, symptomatic with exertion, and chronic limb-threatening
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ischemia.
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A new recommendation is against revascularization for asymptomatic peripheral
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artery disease.
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For symptomatic cases, revascularization is recommended only after a period of supervised
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exercise training and optimal medical therapy, and it should be done in a multidisciplinary
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setting.
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The guidelines also call for at least annual follow-up for these patients.
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The guidelines also standardize measurements and nomenclature for aortic disease and
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recommend the use of CT and cardiac MRI depending on availability and expertise.
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This is crucial because most decisions will be based on the diameter in a specific region of
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the aorta.
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Consistency in measurement and communication is key.
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Along with these updates, the guidelines offer a range of surgery and endovascular procedure
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recommendations for aortic root and ascending aorta dilatation.
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They also provide an algorithm to help reduce delays in diagnosis and referral to an expert
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center, as well as an easy medication management algorithm.
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Finally, let's discuss the updates on hypertension.
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The new guidelines have streamlined the diagnostic categories into just three:
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hypertension, elevated, and non-elevated.
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They emphasize out-of-office measurement for both diagnosis and management and provide
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equivalents to in-office measurements.
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One of the highlighted recommendations is for patients with hypertension to increase their
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potassium intake.
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There's now substantial evidence indicating that increasing potassium intake, particularly
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in patients without moderate to advanced kidney disease, is beneficial.
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This can be achieved through sodium-substitution salt or a high potassium
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diet such as the DASH diet or the Mediterranean diet.
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In terms of treatment, the guidelines recommend starting with combination therapy for
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hypertension and aiming for a target of 120 to 129 millimeters of mercury within three months,
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or as low as reasonably achievable if not feasible due to poor tolerance.
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For resistant hypertension that remains uncontrolled despite medication
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intensification, renal denervation is included as an option under shared decision-making and
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when performed at a medium- to high-volume center.
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That wraps up our coverage of the new ESC guidelines.
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These updates are designed to simplify and improve the management of cardiovascular
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conditions, ultimately leading to better patient outcomes.
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Stay tuned for more updates and insights in our upcoming segments.
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Thank you for listening to Morning Medical with Dr.
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Chow.
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Switching gears now, let's talk about a fascinating new development in respiratory
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health monitoring.
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Researchers have developed and validated a prototype of a smart mask designed to
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continuously monitor exhaled breath condensate, or EBC.
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This novel device, known as the EBCare mask, has shown promising results in pilot studies.
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The EBCare mask looks similar to a KF94 mask and employs a self-cooling strategy, an
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automated microfluidic system, an electrochemical sensor array, and a wireless
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reading circuit.
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According to Wei Gao, PhD, from the California Institute of Technology in Pasadena, this mask
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provides real-time monitoring of multiple biomarkers simultaneously, which is a
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significant advancement over previous smart masks.
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One of the key features of the EBCare mask is its tandem cooling and bioinspired microfluidic
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design, which ensures efficient EBC collection and transport.
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This enables in situ quantitative analysis, making it a highly effective tool for
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respiratory monitoring.
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Gao also highlighted that the integration of highly selective electrochemical biosensors
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enhances the mask's capability to provide detailed molecular insights that were
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previously inaccessible with other wearable technologies.
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Exhaled breath condensate is a noninvasive aqueous matrix in which soluble gaseous and
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nonvolatile biomarkers can be measured.
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Clinically, EBC is collected using commercial condensers or condensation instruments and then
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analyzed in a lab to assess airway inflammation and substance metabolism.
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Traditional EBC capture methods rely on external refrigeration, which can be
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cumbersome.
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However, the EBCare mask uses a passive cooling system to effectively chill exhaled breath,
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simplifying the process considerably.
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This research was motivated by the critical need for comprehensive respiratory monitoring,
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especially in light of recent respiratory pandemics.
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The researchers validated the EBCare mask in various real-life settings, including pilot
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studies with 31 healthy adults, 12 people newly recovered from COVID-19, 10 smokers, 10 people
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with asthma, and 9 people with chronic obstructive pulmonary disease, or COPD.
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Over a span of 14 hours, participants engaged in both indoor and outdoor activities such as
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exercise, eating, drinking, office work, and napping, wearing the mask the entire time
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except for brief eating periods.
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The pilot studies yielded some interesting findings.
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For instance, ammonium concentration in exhaled breath slightly decreased after breakfast but
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increased considerably after protein-rich meals.
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Alcohol consumption resulted in a rapid elevation of EBC alcohol concentration, levels
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comparable to blood alcohol concentration.
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Patients with asthma had higher nitrite levels than controls, suggesting that EBC nitrite
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could help diagnose, monitor, or manage asthma and other respiratory conditions.
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To further demonstrate the clinical significance of EBC nitrite in asthma and other
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respiratory diseases, the researchers validated the EBCare sensors against fractional exhaled
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nitric acid, or FeNO, finding a strong correlation between EBC nitrite and FeNO
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levels.
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Elevated EBC ammonium in COPD patients potentially indicated higher serum urea, and a
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lower EBC pH may be related to airway acidification in asthma patients.
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Wei Gao stated that the EBCare mask effectively monitors a range of biomarkers, including
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ammonium, pH, nitrite, and alcohol, across various indoor and outdoor activities.
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This could have significant implications for monitoring respiratory conditions and metabolic
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disorders, as well as in managing respiratory pandemics like COVID-19.
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The alcohol metabolism monitoring capabilities could also be useful for law enforcement or
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individuals.
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Raed Dweik, MD, chief of the Integrated Hospital Care Institute at the Cleveland Clinic
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in Ohio, noted that historically, devices to collect EBC have been bulky and cumbersome.
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The ability to collect breath condensate in a simple, reproducible, easy, and portable way is
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novel and exciting.
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While there are other ways to measure nitrite, alcohol, ammonia, and pH, Gao and his team
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demonstrated that these biomarkers could be measured in EBC using the mask.
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However, Dweik pointed out that the immediate clinical application of the EBCare mask remains
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unclear, although he sees its potential.
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Future studies will need to determine whether the device helps in diagnosis, monitoring, and
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follow-up, and whether it can measure additional biomarkers.
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Looking ahead, the researchers aim to expand the range of biomarkers that the EBCare mask
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can detect and perform more trials to validate its use in diverse populations and settings.
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They also hope to further develop the device for affordable mass production and explore the
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possibility of integrated data analytics.
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This could pave the way for more comprehensive and accessible respiratory monitoring solutions
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in the future.
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Whooping cough is making a surge in Canada at a time when schools are reopening and ahead of
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the fall respiratory illness season.
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Some provinces, including Ontario, Quebec, and New Brunswick, have reported sharp increases in
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whooping cough cases compared with pre-pandemic averages.
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Whooping cough is a bacterial illness that can be seasonal, peaking in late summer and early
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fall, according to Dr.
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Anna Banerji, a pediatric infectious diseases specialist in Toronto.
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With kids returning to school, experts warn that cases could rise even higher.
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Dr.
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Banerji explains, “I think that now that kids are going back to school and some of the kids
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are not completely vaccinated, I expect to see an increase.
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We’ve already had huge numbers, four times the normal rate of whooping cough that we normally
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see across Canada and really around the world, but I think that might even go up as kids go
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back to school.”
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Dr.
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Earl Rubin, a pediatric infectious disease specialist in Montreal, agrees that schools can
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play a role in whooping cough spread and “certainly increase the risks of transmission.”
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Like respiratory viruses such as influenza, respiratory syncytial virus, and COVID-19,
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bacterial infections like whooping cough are more common during the fall and winter months,
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says Dr.
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Isaac Bogoch, an infectious diseases specialist at Toronto General Hospital.
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So, how can you tell the difference between whooping cough and a common cold?
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Whooping cough, also known as pertussis, is a highly contagious respiratory infection.
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The bacteria that cause whooping cough spread easily from person to person through the air.
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When a person with whooping cough sneezes or coughs, they release small particles containing
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the bacteria, which other people can then breathe in.
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Dr.
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Banerji notes that a distance of about one meter is enough to get exposed.
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Dr.
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Bogoch adds that while whooping cough infection can be more pronounced and severe in the
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youngest population, it can affect people of all ages.
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“It’s important to recognize that whooping cough can affect anybody of any age,” he says.
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Whooping cough symptoms typically start appearing within a week to 10 days after
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exposure to the bacteria, but sometimes it can take as long as four weeks, according to the
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Public Health Agency of Canada.
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The early symptoms of whooping cough make it appear as if it’s a common cold, with a
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low-grade fever, runny or stuffed-up nose, red watery eyes, and a mild, occasional cough.
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“The initial week or so would be indistinguishable from other upper respiratory
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tract infections,” Dr.
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Bogoch explains.
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“But the hallmark feature of whooping cough is a prolonged and severe cough.”
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The illness can evolve over several weeks to include coughing fits that often end with a
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high-pitched “whoop” sound when an infected person is catching their breath.
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The coughing fits may cause difficulty breathing, choking, and vomiting, according to
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the Public Health Agency of Canada.
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The coughing spells can also make people feel very tired, have difficulty sleeping at night,
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or even fracture a rib.
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Dr.
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Banerji adds that since it’s a “very violent cough,” people can also turn blue or rupture
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blood vessels in their eyes.
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Coughing fits can last one to 10 weeks, which is why this illness is often called the
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“100-day cough,” says Dr.
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Bogoch.
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Babies and young children are at greatest risk, as their symptoms can be more severe and they
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could develop serious complications such as weight loss, apnea, pneumonia, convulsions, and
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brain damage.
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There is also a risk of death for the youngest cohort.
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Teenagers and adults can get pneumonia as well from whooping cough, but complications are
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usually less serious in older age groups.
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A nasal test can confirm if a person has whooping cough or not.
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The best way to prevent whooping cough infection is through vaccination, according to
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experts.
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Vaccines that protect children against whooping cough are part of Canada’s routine immunization
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program, beginning at two months old.
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Primary immunization requires four doses, followed by booster shots later in childhood
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and adolescence.
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A dose of acellular pertussis-containing vaccine is also recommended for adults and
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during pregnancy.
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Vaccinated people can still get sick with whooping cough, but the illness is generally
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milder, according to the Centers for Disease Control and Prevention.
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Dr.
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Banerji notes that the pertussis vaccine is “very effective,” but the immunity can wane
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over decades, so parents should make sure children going back to school are up to date on
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their vaccinations.
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If a child is sick, they should stay home until treated to reduce the infectiousness.
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Antibiotics can help treat whooping cough and should be given early in the illness to reduce
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the severity and perhaps even avoid the coughing spells, Dr.
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Banerji advises.
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Once the whooping cough phase is established, taking fluids and rest can help manage the
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symptoms.
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Let's switch topics now and address a concern that has been around for quite some time: the
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potential link between mobile phone use and brain cancer.
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A major systematic review, commissioned by the World Health Organization, has just been
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published in the journal Environment International, and it provides some reassuring
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news.
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The review, conducted by researchers Sarah Loughran from the University of Wollongong and
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Ken Karipidis from Monash University, analyzed 28 years of research on the subject.
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The findings are clear: there is no association between mobile phone radio waves and brain
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cancer or any other health issues.
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Mobile phones emit radio waves, a type of non-ionizing radiation.
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Because these devices are often held against the head during use, concerns emerged that this
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radiation might cause brain cancer.
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However, the scientific consensus has remained strong over the years that there is no such
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link.
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In 2011, the International Agency for Research on Cancer, or IARC, classified radio wave
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exposure as a possible carcinogen to humans based on limited evidence from human
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observational studies.
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This classification led to increased public concern, although it was largely misunderstood.
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Observational studies, while valuable, can often produce biased results.
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For instance, people with brain cancer might report higher mobile phone use than they
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actually had, as seen in the INTERPHONE study.
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The new systematic review builds on a much larger dataset than what the IARC examined in
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2011, incorporating more recent and comprehensive studies.
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This allows for greater confidence in the findings that radio waves from mobile phones or
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wireless technologies do not increase the risk of brain cancer.
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This review is part of a series of systematic reviews commissioned by the World Health
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Organization to closely examine the potential health effects of radio wave exposure.
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It is the most extensive review on this topic to date, considering over 5,000 studies, of
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which 63 were included in the final analysis.
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The main reason for excluding other studies was their lack of relevance, which is typical in
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systematic reviews.
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The review found no association between mobile phone use and brain cancer or any other head or
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neck cancer.
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This held true even for those who used mobile phones for ten or more years.
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Neither the frequency of calls nor the duration of phone use made any difference in cancer
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risk.
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Importantly, these findings align with previous research.
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Despite the massive increase in wireless technology use over the past few decades, there
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has been no corresponding rise in brain cancer incidence.
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This should be reassuring for anyone concerned about the safety of their mobile phone use.
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The results are indeed reassuring.
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They confirm that our national and international safety limits are protective.
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Mobile phones emit low-level radio waves well below these safety thresholds, and there is no
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evidence that this exposure impacts human health.
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However, it's crucial to continue research in this area.
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Technology is evolving rapidly, and new devices may use radio waves in different ways and at
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different frequencies.
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Ongoing research will ensure that these exposures remain safe.
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The challenge now is to counteract the persistent misconceptions and misinformation
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about mobile phones and brain cancer.
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The evidence is clear: there are no established health effects from mobile phone use, and that
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is a good thing.
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That wraps up today's episode of Morning Medical with Dr.
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Chow.
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Thank you for joining me as we explored the latest updates in cardiovascular guidelines,
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innovative respiratory health monitoring, the resurgence of whooping cough, and the
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reassuring findings on mobile phone safety.
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Stay healthy, stay informed, and have a wonderful day.
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Until next time, this is Dr.
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Chi-Ming Chow signing off.