Prognostic Value of Body Mass Index on Short-Term and Long-Term Outcome after Resection of Esophageal Cancer

Introduction: Cachexia and obesity have been suggested to be risk factors for postoperative complications. However, high body mass index (BMI) might result in a higher R0-resection rate because of the presence of more fatty tissue surrounding the tumor. The purpose of this study was to investigate whether BMI is of prognostic value with regard to short-term and long-term outcome in patients who undergo esophagectomy for cancer. Methods: In 556 patients who underwent esophagectomy (1991-2007), clinical and pathological outcome were compared between different BMI classes (underweight, normal weight, overweight, obesity). Results: Overall morbidity, mortality, and reoperation rate did not differ in underweight and obese patients. However, severe complications seemed to occur more often in obese patients (p = 0.06), and the risk for anastomotic leakage increased with higher BMI (12.5% in underweight patients compared with 27.6% in obese patients, p = 0.04). Histopathological assessment showed comparable pTNM stages, although an advanced pT stage was seen more often in patients with low/normal BMI (p = 0.02). A linear association between BMI and R0-resection rate was detected (p = 0.02): 60% in underweight patients compared with 81% in obese patients. However, unlike pT-stage (p < 0.001), BMI was not an independent predictor for R0 resection (p = 0.12). There was no significant difference in overall or disease-free 5-year survival between the BMI classes (p = 0.25 and p = 0.6, respectively). Conclusions: BMI is not of prognostic value with regard to short-term and long-term outcome in patients who undergo esophagectomy for cancer and is not an independent predictor for radical R0 resection. Patients oncologically eligible for esophagectomy should not be denied surgery on the basis of their BMI class

Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials

Background Low-dose aspirin is of definite and substantial net benefit for many people who already have occlusive vascular disease. We have assessed the benefits and risks in primary prevention. Methods We undertook meta-analyses of serious vascular events (myocardial infarction, stroke, or vascular death) and major bleeds in six primary prevention trials (95000 individuals at low average risk, 660000 person-years, 3554 serious vascular events) and 16 secondary prevention trials (17000 individuals at high average risk, 43 000 person-years, 3306 serious vascular events) that compared long-term aspirin versus control. We report intention-to-treat analyses of first events during the scheduled treatment period. Findings in the primary prevention trials, aspirin allocation yielded a 12% proportional reduction in serious vascular events (0.51% aspirin vs 0.57% control per year, p=0.0001), due mainly to a reduction of about a fifth in non-fatal myocardial infarction (0.18% vs 0.23% per year, p<0.0001). The net effect on stroke was not significant (0.20% vs 0.21% per year, p=0.4: haernorrhagic stroke 0.04% vs 0.03%, p=0.05; other stroke 0.16% vs 0.18% per year, p=0.08). Vascular mortality did not differ significantly (0.19% vs 0.19% per year, p=0.7). Aspirin allocation increased major gastrointestinal and extracranial bleeds (0.10% vs 0.07% per year, p<0.0001), and the main risk factors for coronary disease were also risk factors for bleeding. In the secondary prevention trials, aspirin allocation yielded a greater absolute reduction in serious vascular events (6.7% vs 8.2% per year, p<0.0001), with a non-significant increase in haernorrhagic stroke but reductions of about a fifth in total stroke (2.08% vs 2.54% per year, p=0.002) and in coronary events (4.3% vs 5.3% per year, p<0.0001). In both primary and secondary prevention trials, the proportional reductions in the aggregate of all serious vascular events seemed similar for men and women. Interpretation In primary prevention without previous disease, aspirin is of uncertain net value as the reduction in occlusive events needs to be weighed against any increase in major bleeds. Further trials are in progress. Funding UK Medical Research Council, British Heart Foundation, Cancer Research UK, and the European Community Biomed Programme

Risk assessment and treatment benefit in intensively treated hypertensive patients of the Hypertension Optimal Treatment (HOT) study

BACKGROUND: The Hypertension Optimal Treatment (HOT) Study provided information about cardiovascular events in 18,790 hypertensives, subjected to pronounced blood pressure lowering for a mean of 3.8 years. METHODS AND RESULTS: The HOT Study data have been further analysed after risk stratification of the patients (1999 World Health Organization and International Society of Hypertension guidelines criteria): (i) no patients of the HOT Study were classified as low risk, 50% were classified as medium risk, 20.2% as high risk and 29.8% as very high risk; (ii) incidence of cardiovascular events in these patients with excellent blood pressure control [92% had diastolic blood pressure (DBP) < or = 90 mmHg] remained proportional to pretreatment risk. The relative risk of very high- versus medium-risk strata was between two and three both when HOT Study patients were considered independently of, or within the DBP target group they had been randomized to; and (iii) event rates in all risk strata were calculated to be much lower (possibly 60% lower) than rates expected from baseline risk calculated approximately by the Framingham equation. CONCLUSIONS: The low event rate in HOT Study patients is likely to result from pronounced blood pressure lowering, and is not explained by a lower risk profile than in previous controlled trials of antihypertensive treatment. The persistence of a risk gradient despite intensive blood pressure lowering suggests a combination of blood pressure control with other strategies of risk correction and the need to initiate antihypertensive therapy before complications develop

Benefit and harm of low-dose aspirin in well-treated hypertensives at different baseline cardiovascular risk

BACKGROUND: The effects of aspirin in subjects without cardiovascular disease are controversial. In the intensively treated patients of the Hypertension Optimal Treatment (HOT) Study, randomization to low-dose aspirin (75 mg daily) versus placebo significantly reduced cardiovascular events (-15%) and myocardial infarction (-36%), but increased major bleedings (+65%). The present analyses of HOT Study data aim at identifying subgroups of hypertensives with different benefit-to-harm ratios from aspirin, in order to provide recommendations about the use of aspirin in hypertension. METHODS: The 18 790 hypertensive patients (aspirin 9399, placebo 9391; average treatment duration 3.8 years) were stratified for global cardiovascular risk and for individual risk factors. Subgroup-treatment interaction analyses (end points: cardiovascular events, myocardial infarction, major bleedings) were performed by a Cox proportional hazard model. Relative and absolute benefits and harms were calculated. RESULTS: Interaction analyses indicated that of all subgroups, only patients with serum creatinine > 1.3 mg/dl had a significantly greater reduction of cardiovascular events and myocardial infarction (-13 and -7/1000 patient-years), while risk of bleeding was not significantly different between subgroups. In addition to patients with higher creatinine, a favourable balance between benefit and harm of aspirin was found in subgroups of patients at higher global baseline risk and baseline systolic pressure > or = 180 or diastolic pressure > or = 107 mmHg. CONCLUSIONS: Low-dose aspirin should be recommended to well-treated hypertensive patients with even moderate increase in serum creatinine. Aspirin may also be recommended in well-treated hypertensives at higher global cardiovascular risk or higher initial blood pressures

Influence of gender and age on preventing cardiovascular disease by antihypertensive treatment and acetylsalicylic acid. The HOT study

OBJECTIVE: We have assessed the influence of gender and age on the main outcome results of the Hypertension Optimal Treatment (HOT) study. DESIGN AND INTERVENTIONS: The aims of the HOT study were to study the relationship between three levels of target office diastolic blood pressure (BP) ( or = 65 years (P = 0.04) but was influenced by gender (P = 0.38 in women and P = 0.001 in men, lowered by 42% corresponding to a reduction from 5.0 to 2.9 MIs/1000 patient-years). CONCLUSIONS: The data of this HOT study sub-analysis suggest somewhat differentiated optimal gender- and age-dependent effects of anti-hypertensive and anti-platelet therapies; lowering of diastolic BP to about 80 mmHg in hypertensive women and, in addition, the administration of 75 mg of ASA to well-treated hypertensive men appear to effectively reduce the most common cardiovascular complication, i.e. myocardial infarction, in patients with essential hypertension

Primary prevention of sudden cardiovascular death in hypertensive patients mortality results from the maphy study

In a randomized primary prevention trial including 3, 234 men with mild to moderate uncomplicated hypertension, the effect of the β-blocker metoprolol or a thiazide diuretic as an initial antihypertensive therapy was compared regarding the risk of sudden cardiovascular death during a follow-up ranging from 2.3 to 10.8 years (median of 4.2 years). Only men aged 40 to 64 years were included in the study. The randomization of patients into the metoprolol (n = 1, 609) or diuretic group (n = 1, 625) was per­formed after stratification for age, smoking habits, serum cholesterol, and systolic blood pressure. At baseline the two treatment groups were well matched. Metoprolol was given in a mean dose of 174 mg daily and the mean dose of thiazide diuretic was either 46 mg hydrochlorothiazide daily or 4.4 mg bendroflumethiazide daily. Identical blood pressure control was achieved using the fixed therapeutic schedule. Total and car­diovascular mortality were significantly lower for metoprolol than for diuretics, owing to fewer deaths from coronary heart disease and stroke. Of the car­diovascular deaths, 78% were classified as sudden cardiovascular deaths (occurred within 24 h after the onset of symptoms). There were significantly fewer sudden cardiovascular deaths in the meto­prolol group compared to the diuretic group (32 v 45, P =.017). The present results suggest that initial antihypertensive therapy with metoprolol is asso­ciated with a lesser incidence of sudden cardiovas­cular deaths than initial diuretic treatment in un­complicated hypertension. © 1991 by the American Journal of Hypertension, Inc

Body mass index: different nutritional status according to WHO, OPAS and Lipschitz classifications in gastrointestinal cancer patients

CONTEXT: The body mass index (BMI) is the most common marker used on diagnoses of the nutritional status. The great advantage of this index is the easy way to measure, the low cost, the good correlation with the fat mass and the association to morbidity and mortality. OBJECTIVE: To compare the BMI differences according to the WHO, OPAS and Lipschitz classification. METHODS: A prospective study on 352 patients with esophageal, gastric or colorectal cancer was done. The BMI was calculated and analyzed by the classification of WHO, Lipschitz and OPAS. RESULTS: The mean age was 62.1 ± 12.4 years and 59% of them had more than 59 years. The BMI had not difference between the genders in patients <59 years (P = 0.75), but over 59 years the BMI was higher in women (P<0.01). The percentage of undernourished was 7%, 18% and 21% (P<0.01) by WHO, Lipschitz and OPAS, respectively. The overweight/obesity was also different among the various classifications (P<0.01). CONCLUSIONS: Most of the patients with gastrointestinal cancer had more than 65 years. A different cut off must be used for this patients, because undernourished patients may be wrongly considered well nourished

METOPROLOL VERSUS THIAZIDE DIURETICS IN HYPERTENSION - MORBIDITY RESULTS FROM THE MAPHY STUDY

The present study in hypertensive men (40-64 years old) with untreated diastolic blood pressure above 100 mm Hg was aimed at investigating whether metoprolol (n = 1,609) given as initial treatment would lower the risk for coronary events (sudden death and myocardial infarction) more effectively than thiazide diuretics (n = 1,625). A substantial part of this study was the metoprolol arm of the Heart Attack Primary Prevention in Hypertension (HAPPHY) study. The HAPPHY study was a pooling of the effect of different beta-blockers, mainly metoprolol and atenolol, in which no favorable effect in relative risk was observed for atenolol as compared with diuretics. In the present study, 255 patients suffered definite coronary events during follow-up; 25% of these events were fatal, 39% were acute myocardial infarctions, and 36% were silent myocardial infarctions. The risk for coronary events was significantly lower in patients on metoprolol than in patients on diuretics (111 versus 144 cases, p = 0.001, corresponding to 14.3 versus 18.8 cases/1,000 patient years and a relative risk of 0.76 at the end of the trial; 95% confidence interval 0.58-0.98). This difference in risk has potentially important implications for clinical practice because of the large number of hypertensive patients who are at increased risk for coronary events. Because a placebo group, for ethical reasons, could not be included, relative risk can only be expressed in relation to diuretics. There was no difference between the two treatment groups in baseline characteristics, blood pressure during follow-up, or stroke rates. Thus, the difference in risk for coronary events is probably mediated via mechanisms other than blood pressure control. However, present data might suggest that different beta-blockers may have different efficacy in preventing coronary events. The reasons for this possibility are as yet unknown