Chiefs’ Inquiry Corner- 9/6/21

September 9, 2021


Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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 A recent retrospective, multinational cohort study examined two groups of patients initiating treatment for hypertension; one group started therapy with ACE inhibitors (N=2297881) and the other group started therapy with ARBs (N=673938). Primary outcomes compared between the two groups included acute myocardial infarction, heart failure, stroke, and composite cardiovascular events. Secondary outcomes (which also included safety outcomes) included rates of angioedema, cough, syncope, electrolyte derangements, GI bleeding, and acute pancreatitis, among others. There was no statistically significant difference between ACE inhibitors and ARBs as related to primary outcomes. However, those taking ARBs had significantly lower risk of angioedema, cough, pancreatitis, and GI bleeding as compared to those taking ACE inhibitors. With equivalent efficacy but a comparatively better safety profile, this study suggests ARBs should preferentially be prescribed over ACE inhibitors when initiating treatment for hypertension.

References: Comparative First-Line Effectiveness and Safety of ACE (Angiotensin-Converting Enzyme) Inhibitors and Angiotensin Receptor Blockers: A Multinational Cohort Study
  Infliximab is a monoclonal antibody that binds and blocks the effects of TNF-α. It is used to treat several inflammatory diseases including Crohn disease, ulcerative colitis, ankylosing spondylitis, and psoriasis; it is also used as an adjunct in rheumatoid arthritis and immunotherapy-related colitis. Immediate transfusion reactions to infliximab can happen within 1-2 hours of infusion and can include symptoms of pruritus, flushing, dyspnea, chest discomfort, hypertension, myalgia, nausea, headache, rash, and dizziness; they are estimated to occur in 5-23% of patients receiving this drug. In particular, people with inflammatory bowel disease treated with infliximab who develop antibodies toward infliximab have a 2-fold risk of acute infusion reactions (and 6x risk of serious acute infusion reactions). Delayed transfusion reactions occur at > 24 hours post-transfusion and mimic serum sickness with symptoms of pruritus, fever, malaise, and polyarthralgia; they are less common than acute reactions, occurring in approximately 1-3% of patients receiving this drug.

References: Infliximab-Related Infusion Reactions: Systematic Review
 Dyspnea is a common symptom in those with end stage renal disease. Pulmonary hypertension has been noted to be present via echocardiography in 17-56% of patients with ESRD on dialysis and is an independent predictor of mortality. In a small prospective observational study of 62 patients with dyspnea of unknown origin & CKD, pHTN was observed in 81% of HD patients and 71% of patients with CKD stages 4-5 as measured by RHC. This study observed that most CKD patients had post-capillary pHTN, but 10% of HD patients had pre-capillary pHTN without identifiable etiology. There were no cases of precapillary pHTN in nondialysis CKD patients. This suggests that dialysis itself may trigger the development of precapillary pulmonary hypertension through mechanisms such as impaired endothelin function, or decreased bioavailability of nitric oxide. Other mechanisms by which dialysis could increase pulmonary artery pressure include high cardiac output related to arteriovenous access, renal anemia and fluid overload.

References: Pulmonary Hypertension in Patients with Chronic Kidney Disease on Dialysis and without Dialysis: Results of the PEPPER-Study