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Hydrochlorothiazide as Effective as Chlorthalidone for Preventing CVD, Death in Hypertension
There were no significant differences in cardiovascular outcomes, including death, between use of hydrochlorothiazide or chlorthalidone among older adults with hypertension, according to new research presented at the American Heart Association’s (AHA) Scientific Sessions 2022.
Presented by Areef Ishani, MD, results of The Diuretic Comparison Project, which enrolled more than 13,000 participants with hypertension, suggest there were no difference in cardiovascular outcomes or noncancer deaths with use of chlorthalidone over hydrochlorothiazide, but investigators pointed out subgroup analyses suggested chlorthalidone could provide benefit in those with a history of cardiovascular disease or stroke.
“We were surprised by these results,” said Ishani, the director of the Minneapolis Primary Care and Specialty Care Integrated Care Community and the director of the VA Midwest Health Care Network in Minneapolis, in a statement. “We expected chlorthalidone to be more effective overall, however, learning about these differences in patients who have a history of cardiovascular disease may affect patient care. It’s best for people to talk with their health care clinicians about which of these medications is better for their individual needs.”
A paradox exists in the management of hypertension in the US. Although recent guidelines recommend chlorthalidone over other diuretics for treatment of hypertension, real-world data suggests hydrochlorothiazide remains the preferred choice for most clinicians prescribing diuretics for management of hypertension. Launched in 2016, the Diuretic Comparison Project was created with the intent of enrolling 13,500 Veterans with hypertension identified using national Veterans Affairs (VA) and non-VA databases with a follow-up of 3 years to better understand how diuretic choice might influence clinical outcomes.
An open-label study, patients were randomized to remain on current dose of hydrochlorothiazide or converted to an equipotent dose of chlorthalidone. For inclusion in the study, patients needed to be at least 65, be receiving hydrochlorothiazide from the VA, and have a most recent systolic blood pressure reading at or exceeding 120 mmHg. The primary outcome of interest for the study was a composite of major adverse cardiovascular events that included stroke, myocardial infarction, hospitalization for heart failure, urgent coronary revascularization, and non cancer death.
Overall, 16,595 individuals from 500 medical centers across the US underwent screening for participation. Of these, 13,523 underwent randomization, with 6756 randomized to chlorthalidone and 6767 randomized to hydrochlorothiazide. The overall study population had a mean baseline systolic blood pressure of 139 mmHg, was 97% men, 77% White, 93% non-Hispanic, and 55% reported living in urban areas. The median length of follow-up for the study was 2.4 years.
Upon analysis, results indicated a primary outcome event occurred among 10.4% of those receiving chlorthalidone and 10.0% of those receiving hydrochlorothiazide (HR, 1.04 [95% CI, 0.94-1.16]; P=.04). Further analysis indicated the rate of cardiovascular disease or death was 9.4% with chlorthalidone and 9.3% with hydrochlorothiazide. Investigators pointed out there were no significant differences observed for incidence of myocardial infarction, stroke, heart failure, or other cardiovascular outcomes observed in their analyses.
However, investigators pointed out differences of note were observed in subgroups analyses. Specifically, those with a history of myocardial infraction or stroke receiving chlorthalidone experienced a 27% relative risk reduction for all-cause mortality and cardiovascular disease compared with hydrochlorothiazide, but chlorthalidone did appear to worsen these same outcomes in those without a history of myocardial infarction or stroke. Additional analyses revealed there were increased rates of hospitalization with hypokalemia among those randomized to chlorthalidone (1.5%) compared to those randomized to hydrochlorothiazide (1.1%).
“We were surprised by these results,” Ishani said. “We expected chlorthalidone to be more effective overall, however, learning about these differences in patients who have a history of cardiovascular disease may affect patient care. It’s best for people to talk with their health care clinicians about which of these medications is better for their individual needs.
This study, “Chlorthalidone compared with Hydrochlorothiazide for the prevention of cardiovascular events in patients with hypertension: The Diuretic Comparison Project (DCP),” was presented at AHA 22.
B.C. initiative aims to expand genetic screening for Ashkenazi Jewish people at risk of hereditary cancers
The final gift Catriona Remocker’s father gave her was discovered by a lab in a vial of his blood.
Dr. Geoffrey Remocker died of Stage IV prostate cancer in 2016, just two weeks after testing confirmed he was a carrier for genetic mutations that increase the likelihood of developing ovarian, breast, prostate and pancreatic cancers.
These hereditary BRCA1 and BRCA2 mutations are ten times more common among both men and women of Ashkenazi Jewish descent, like Remocker and her father, than non-Jewish people.
About one in 40 individuals with Ashkenazi heritage carry the mutations, according to the U.S. Centre for Disease Control, which increase the likelihood of women developing ovarian cancer, for example, from one per cent to 30 per cent before age 70.
Both men and women are at risk, though most people know only of their links to breast and ovarian cancer.
“It’s not guaranteed that you will develop cancer, but there may be a mutation in a gene that is associated with cancer that puts you at the higher risk,” said Dr. Sophie Sun, co-director of B.C. Cancer’s Hereditary Cancer program.
The increased risk is likely because founding members of the Ashkenazi Jewish community, in Central and Eastern Europe, had such mutations and then reproduced in relative isolation.
But without a family history of cancer, Remocker says she was “shocked and surprised” to find out her father was a carrier, and later, that she carries the mutation as well.
“We didn’t know that as people with Jewish heritage we were at increased risk,” said Remocker, who co-founded non-profit BRCA in BC with her mother, Jane Remocker.
The Remockers are now teaming up with B.C. Cancer’s Hereditary Cancer program to expand genetic testing for Jewish people in B.C. to save them the same shock and pain.
Ashkenazi Jewish people in B.C. qualify for free genetic testing if they have a history of cancer in their families, Sun said.
But due to genocide during the Holocaust and displacement, many people don’t know they have such heritage or that their risk of certain cancers, among both men and women, are heightened.
An imminent pilot project, largely funded by Vancouver’s Diamond Foundation, will study the prevalence of the BRCA mutations among Ashkenazi Jewish peoples in B.C. and aims to offer free, voluntary genetic testing to everyone with that heritage, regardless of family cancer history.
Early detection of the mutations when one is young and healthy can help avoid invasive treatments if cancer does develop and thereby save lives, said Sun.
“Some of these cancers are potentially preventable,” she said.
Empowerment through early detection
Knowing she carried the gene allowed Remocker, now 39, to qualify for regular scans and take measures to reduce her risk of developing cancer, including a mastectomy to remove her breast tissue before the recommended age of 40.
“I’m a lot more empowered and I have a lot more tools to deal with it and to do something about my risk,” said Remocker. “It was really hard watching my dad go through what he went through and that’s certainly not something I want for myself.”
Sun says people should get as familiar with their family histories as possible, and speak to a doctor or visit the Hereditary Cancer program website to see if they are eligible for free testing.
But raising awareness among the Jewish community in B.C. is difficult, said Remocker. There are only around 35,000 Jewish people in B.C, according to a 2019 estimate from the Jewish Federations of North America, and Remocker says they are more “fragmented” than in other cities with more established Jewish communities and dedicated hospitals.
Remocker hopes spreading the word will ensure others can make the decision to get tested for the mutations without having to lose a loved one.
She said that it was “really important that we start to develop more of a voice for Jewish people in the province around these health issues.”
Coming to Terms with My Baby’s Food Allergies
Please note that this information is based on personal experience with baby’s food allergies and should not take the place of the advice of a medical professional. If you suspect your child is having an allergic reaction please seek immediate medical attention.
Our First Experience with Baby’s Food Allergies
I wasn’t exactly sure why, but when my daughter Elise hit six months-old and it was time for her to start eating solids, I was extremely nervous to introduce allergens. I put it off month after month until my doctor reminded me that introducing allergens before your child’s first birthday reduces their chances of developing lifelong allergies. I discussed my concerns and she told me that we wouldn’t know unless we tried. Our families didn’t have a history of food allergies, so there was no reason to continue putting it off.
The next day I decided to take our doctor’s advice to start introducing allergens to Elise’s diet. I knew that peanut butter when served on its own was a choking hazard, so I mixed a teaspoon of peanut butter with two teaspoons of her favourite fruit and veggie puree to thin it out. I plopped her in her highchair and decided to go for it. I placed a spoonful of the mixture into her mouth. She made a happy sound and opened her mouth for more. I gave her another spoonful and waited a few minutes. She seemed fine. I was starting to feel like we were out of the woods. She asked for more and as I was filling another spoon with food something in her eyes changed. I examined her face and saw that her cheeks and underneath her chin were more red than usual. Seconds later, hives began forming and spread across her face.
We had just moved into a new home a few months prior, and proximity to a hospital hadn’t been at the top of my “must haves” list. Whether the home was move in ready, had the correct number of bedrooms and more than one bathroom had been my main concerns. At the time, being twenty minutes away from the closest hospital did not seem unreasonable. Sitting there watching the hives and redness spread like a wave over her face I fell deep into mom guilt. Why the hell hadn’t being around the corner from a hospital been at the top of my list? I have children and emergencies can happen at any time. Shouldn’t a hospital have been more important than an extra bathroom?
And why did I decide to give her a top allergen at home? If I had been smarter I would have driven to a hospital and given her the peanut butter there, that way if she reacted I could’ve just run inside and she would have received immediate attention. Stupid! You stupid, horrible mother!
I grabbed my phone with shaking hands and called 911. I had never had to dial for an ambulance or the police before, I had never been in an emergency. The small red hives were now down her neck and continuing underneath her clothes. Elise was screeching and clawing at the itchy bumps all over her body. Her ears were red and swollen now. What was happening? Were the hives in her throat? Was her throat going to close? Was my baby going to die? I could feel the tears running down my face, but I had to keep it together. She was the one dealing with a medical emergency. I needed to do everything I could to get her through it. She was still screaming, but screaming was good. Screaming meant she could still breathe.
The emergency operator picked up the phone, “Hello 911. What’s your emergency?”
“Hi, I gave my daughter peanuts for the first time and she is having a major allergic reaction. I need paramedics.”
The operator told me the fire department and ambulance was on its way. She asked me to describe what was happening and provide our personal information. I held my baby and began packing up in case we were going to the hospital. She told me to remain calm and asked for updates. She stayed on the line until they arrived. The fire department arrived first, with the ambulance five minutes behind them. The paramedics looked my daughter over and hooked her up to a machine to check her oxygen levels. While they were helping her the allergic reaction began to go down. After an hour had passed since her initial reaction they thought that she was stable and went to head out to their next emergency. Before they left they gave Elise a moose stuffed animal that was wearing a paramedics t-shirt and told me that I did the right thing by calling.
I took Elise upstairs, nursed her, and held her close. I closed my eyes and took some deep breaths. I would call the doctor in the morning and find out if she needed an EpiPen and also ask for a referral to an allergist. While I was just beginning to relax, Elise started squirming aggressively in my arms and making unhappy sounds. I looked down and a fresh batch of hives were making their way around the back of her neck. They were moving fast and soon were on her cheeks and even on one of her eyelids. The angry hives stopped looking like small bumps and started to look more like water blisters. The blister-like hives were getting bigger and bigger and began to merge into super-hives.
My daughter didn’t even look like herself anymore. A blister expanded and took over her eye, it was now swollen shut. She unlatched her swollen lips and began screeching again. NO, NO, NO! Please, not again! I was so confused. Could there have been left over peanut residue in her mouth that was rinsed down while she was nursing? Why was a new reaction happening?
I called 911 again. The paramedics were on their way back. When the same paramedics walked through the door they looked surprised at how much bigger Elise’s second reaction was. They examined her again and told me to grab our bags and put her in her car seat, we were going to the hospital. They strapped the car seat to the stretcher and off we went. Elise was
mesmerized by all of the lights and beeping equipment in the ambulance. She pointed at different items and looked over to make sure I was paying close attention to everything that she was showing me. I nodded and gave her the words for as many items as I could. I told her that she was brave and that I loved her. I told her the hospital was going to make her all better and we’d be able to go back home soon. She seemed very uncomfortable, still itching and unable to see out of one eye.
We got to the hospital and checked in. We were given a room in the ER and then it was a revolving door of nurses and the doctor coming in and out to look at Elise and monitor her. They administered an EpiPen and it worked like magic. Immediately the hives began to disappear, the swelling went down and Elise looked at me in wonder.
I could tell she was starting to feel better too because she started to babble more and was no longer scratching at her skin. They gave her oral steroids and other medication. They told us we would have to stay until it had been six hours from her initial reaction because multiple waves of allergic reactions were possible.
I learned that because Eli had eczema, she was more likely to have food allergies. Apparently food allergies, eczema, and asthma often go hand-in-hand. The first allergic reaction tends to be the most mild, and Elise would require an EpiPen to be with her at all times moving forward. The doctor prescribed one EpiPen for daycare and two for home. The doctor sent the referral to an allergist and advised me to keep her away from products containing peanuts.
We would now have to be diligent about checking food labels moving forward. My head swam with all of this information and all I kept thinking was, “food could kill my baby.” I felt helpless. I may be able to protect her at home, but what about all of the places she could be exposed to peanuts outside of the house: restaurants, school, camp, planes, friend’s and family’s homes. I opened my phone and sent a quick email to the daycare letting them know of her diagnosis.
It’s now been six months since Elise’s first allergic reaction. Our allergist works with us to navigate Elise’s allergy and I’ve had time to come to terms with her diagnosis. We’ve had to feed her other allergens to rule them out. She’s also had allergy appointments, blood tests, skin prick tests, as well as her first oral food challenge. We are currently considering oral immunotherapy, a treatment where the patient is given increasing amounts of the food they are allergic to in order to build up tolerance to it. We are hopeful that this treatment could help keep her safer in life moving forward.
I still feel that her allergy is out of our control, but we are careful to avoid peanuts and I am thankful that modern day medicine and treatments exist. Elise and her peanut allergy are a package deal. We love her the way she is and so we will manage her food allergy and continue to protect her.
Wellness and rejuvenation on a Whistler weekend
The freshness of spring is giving way to the languor of summer. It’s also that time of year when I step up my health and fitness habits, with the help of a wellness weekend getaway. Check out these ten wholesome ways to experience Whistler.
1. Eat well, be well at a new event series
Making its debut the Nourish Spring Series by Cornucopia celebrates the season every weekend in June with farm-to-table fare, farm tours, lavish wellness dinners, healthy brunches and activities to refresh both mind and body. Sit down to a four-course spring harvest tasting menu (Brome Lake duck breast with Pemberton beets, anyone?), brush up on grilling skills with an expert chef, pick up painting pointers on an art picnic or jump into an outdoor Zumba class. Order tickets online at whistler.com/events/spring-cornucopia.
2. Chill at a spa
With more than 12 spa facilities in town, it could be said that Whistler has everyone’s back. Pop into the Whistler Day Spa for a 75-minute stress relief massage using Swedish relaxation techniques or the Taman Sari Royal Heritage Spa for an 80-minute herbal steam massage using pouches filled with Javanese turmeric, ginger and other spices. Have more time? Dip into the hot-cold-and-relaxing thermal journey at the silent Scandinave Spa Whistler, home to open-air pools, cold-plunge baths, a Finnish sauna, Nordic showers and solariums in a tranquil forest setting.
3. Lace up for new guided hikes
Trek past alpine meadows flush with wildflowers on the way to glacier-fed Garibaldi Lake or meander through a fragrant rainforest before taking a dip in Crater Rim’s warm Loggers Lake. These are just a couple of guided hike options from Mountain Skills Academy & Adventures. Prefer to stay close to town? Sign up for the Whistler Alpine Hike and explore the gondola-accessed terrain of Whistler Blackcomb.
4. Embark on an ebike adventure
Sneak in some good clean fun with an ebike rental or guided tour. Explore Whistler’s car-free Valley Trail, a 46-km network of paved paths and boardwalks linking the resort town’s neighbourhoods and lakes, beaches, parks and viewpoints along the way. Go it alone or hop on a full-suspension electric-assist mountain bike with Whistler Eco Tours for a two-hour guided ride. Prefer an old-school ride or want to hit the alpine trails? Comfort cruisers, cross-country and downhill bikes are also on hand.
5. Expand the mind at an Indigenous exhibit
You have until October to view, the Squamish Lil’wat Cultural Centre’s Unceded: A Photographic Journey into Belonging. Shot at striking locales throughout the Sea to Sky Corridor, the exhibit brings together aspects of ancient traditions, modern Indigenous life, and colonization and development. Behold the bear dancer on Blackcomb Mountain, the cultural chief in the Fairmont Chateau Whistler lobby and the Squamish Nation chair standing in the middle of downtown Vancouver’s West Cordova St.
6. Get down, be healthy at a new café
Boogie back in time to the ’70s and ’80s at the new Rockit Coffee in Whistler Creekside. From the speaker-lined wall and vintage phones, radios and ghetto blasters to menu items like Espresso Greatest Hits and Drinks Just Wanna Have Fun, the colourful café exudes a decidedly retro vibe. Pull up a chair and order a nutritious Aero-Smoothie – choose from the Green Day, Bananarama or Strawberry Fields Forever – and pair it with a Veggie Eilish breakfast wrap or Prosciutto Rhapsody sandwich.
7. Check into wellness
Go for the Fairmont Chateau Whistler’s healthful options like daily yoga classes, guided excursions and access to pools, steam rooms, the fitness centre, tennis court and (soon) new pickle ball courts. But stay for the regionally sourced seasonal menus – complemented by the rooftop garden’s bounty from May to October – and no-proof cocktail selection in the Mallard Lounge.
8. Float down a winding river
Canoe, kayak or stand-up paddleboard along the meandering five-km-long River of Golden Dreams. After putting in at Alta Lake, paddle past riverbanks lined with wildflowers, foliage and forest, all the while keeping an eye out for beavers, otters, eagles and bears. Newbie paddlers are advised to go with a guide, as changing water levels can make for tricky steering and mandatory portages.
9. Connect with nature on a new birding trail
Watch for whiskey jacks, Clark’s nutcrackers and, come summer, lots and lots of swallows along the Sea to Sky Bird Trail. The fifth and most recent route to be added to the BC Bird Trail network along the Pacific Flyway, the new trail takes birders to alpine heights (lift ticket required) where they can spot olive-sided flycatchers and various raptors. Then it’s off to Rainbow Park on Alta Lake to spy common yellow throats and merlins.
10. Wake up beside a lake
Perched along the southern tip of Nita Lake in Whistler Creekside, Nita Lake Lodge checks off all the boxes for a dreamy wellness escape. Start with stunning water and valley views from luxe suites, currently undergoing a modern refresh slated to wrap in time for summer. Then there’s the new onsite restaurant, The Den, where plant-based alternatives share space with meat and seafood items on the seasonal menus. Topping off a salubrious stay at Whistler’s only lakeside hotel is an award-winning spa with rooftop hot tubs.
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