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JAMA. 2004;292:2189.

JAMA-EXPRESS
Antihypertensive Therapy in Normotensive CAD
The optimal blood pressure range for patients with coronary artery disease (CAD) is not established, nor is it known whether patients with so-called normal-range blood pressure might benefit from treatment with blood pressure–lowering drugs. Nissen and colleagues (SEE ARTICLE) report the results of a randomized trial evaluating the effect of amlodipine or enalapril vs placebo on cardiovascular events in normotensive patients with CAD. They found that patients receiving amlodipine had significantly fewer cardiovascular events than patients receiving placebo. For patients receiving enalapril, adverse events were fewer but not statistically different compared with patients receiving placebo. In a subgroup of patients undergoing intravascular ultrasound, patients treated with amlodipine were found to have slowing of atheroma progression. In an editorial, Pepine (SEE ARTICLE) discusses the complexities of determining optimal blood pressure for patients with CAD.

The Metabolic Effects of -Blockers
-Blockers decrease cardiovascular risk in patients with hypertension and type 2 diabetes mellitus (DM); however, they may worsen patients’ glycemic control. Bakris and colleagues report results of a randomized trial of carvedilol vs metoprolol for patients with type 2 DM and hypertension receiving renin-angiotensin system blockade, in which changes from baseline glycosylated hemaglobin (HbA_1c), insulin sensitivity, and microalbuminemia were assessed. Following 5 months of maintenance therapy, the authors found patients receiving carvedilol had significant improvements in HbA_1c and insulin sensitivity and less progression to microalbuminurea compared with patients receiving metoprolol.

(SEE ARTICLE)

The Metabolic Syndrome, Inflammation, and Cognition
The metabolic syndrome is associated with cardiovascular disease, and cardiovascular risk factors increase the risk of cognitive decline. However, whether the metabolic syndrome is associated with cognitive decline is not known. Yaffe and colleagues report results of an observational study of elderly individuals that evaluated the association of the metabolic syndrome and high levels of inflammatory markers with worsening cognition through 4 years of follow-up. They found that participants with the metabolic syndrome had a greater likelihood of cognitive decline compared with those without, and there was a significant interaction of the metabolic syndrome and inflammation on cognitive impairment.

(SEE ARTICLE)

DHEA Effects on Abdominal Fat and Insulin Action
Dehydroepiandrosterone (DHEA), a widely available dietary supplement, reduces abdominal fat and prevents insulin resistance in laboratory animals. Villareal and Holloszy enrolled 56 elderly persons in a randomized placebo-controlled trial to assess whether similar effects are seen in humans. They found significant reductions in visceral and subcutaneous abdominal fat and an increase in insulin sensitivity in the participants assigned to receive DHEA compared with those assigned to receive placebo.

(SEE ARTICLE)

First-Trimester Placentation and Stillbirth Risk
Stillbirth affects approximately 1 in 200 pregnancies. Identification of women at high risk may allow effective intervention. Smith and colleagues investigated whether maternal serum levels of 2 placental proteins—pregnancy-associated plasma protein A (PAPP-A) and free subunit of human chorionic gonadotropin (HCG)—measured during the first 10 weeks of pregnancy could predict the risk of antenatal stillbirth. They found that women with levels of PAPP-A in the lowest fifth percentile had a significantly increased risk of stillbirth due to placental dysfunction and that this risk was independent of maternal characteristics. Maternal levels of free subunit of HCG levels were not related to stillbirth risk.

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Medical News & Perspectives
Success in preventing vision loss in mice with an inherited blinding disorder and other recent studies are demonstrating the potential therapeutic applications of stem cell research.

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CLINICIAN’S CORNER
A Patient Who e-Mails His Physician
Clinical Crossroads
Slack discusses implications of patient e-mail access to clinicians and Internet access to personal medical records for patient-physician communication, patient care, and physician burden. In an editorial, Hersh discusses progress in medical informatics and barriers to its broader adoption.

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Human Monocytic Ehrlichiosis
Grand Rounds
Empirical doxycycline therapy proved life-saving in a patient with human monocytic ehrlichiosis, a disease with few specific clinical clues to diagnosis.

(SEE ARTICLE)

JAMA Patient Page
For your patients: Information about ehrlichiosis.

(SEE ARTICLE)

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