In elderly patients, systolic blood pressure is a stronger predictor of events than diastolic blood pressure.

True. Before 50 years of age, diastolic blood pressure is more important whereas after 50 years of age, systolic blood pressure is a stronger predictor.

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In JNC 7 guidelines, the threshold for pharmacological treatment of hypertension is >=140/90mmHg, except in the presence of diabetes or chronic kidney disease.

True. The goal blood pressure recommended in patients with diabetes and chronic kidney disease is <= 130/80mmHg. In diabetic patients, even small improvement in blood pressure control will make significant reduction in major cardiovascular events (HOT and UKPDS studies). For example, in HOT, there was a 50% reduction in major cardiovascular events in the target group <= 80mmHg compared with the <= 90mmHg group. In patients with chronic kidney disease, defined as either reduced GFR < 60mL/min/1.73m 2 for >= 3 months or the presence of albuminuria (>300mg/d), progression of renal function deterioration is also very sensitive to blood pressure differences. In general, ACEI and ARBs are particularly useful in these two categories of patients.

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In JNC 7 guidelines, for patients with blood pressure > 20/ 10mmHg above the goal, initiation of therapy with two agents should be considered.

True. Clinical trials have shown that 2 or more anti-hypertensive medications are required to achieve goal blood pressures in most hypertensive patients. Accordingly, initiation of therapy with two agents is recommended in JNC 7 guidelines for those at higher risk (i.e. blood pressure >20/10mmHg above goal). In JNC 7, although somewhat controversial, thiazide-type diuretics are recommended as first-line treatment and in combination with other classes when multiple drugs are required.

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In the VALUE study, there was no difference in the primary endpoint, namely the composite endpoint of cardiac morbidity and mortality, between Valsartan (Diovan) and Amlodipine (Norvasc) in the treatment of hypertension.

True. There was no difference in the primary endpoint. For the secondary endpoints, there was significantly less myocardial infarction in the Amlodipine group and there was significantly less new-onset diabetes in the Valsartan group. The outcomes of stroke, congestive heart failure and all-cause mortality were similar in the two groups. It appears that from trials in recent years, the absolute control of blood pressure may be more important than the choice of antihypertensive drugs for cardiovascular risk reduction, although there may be differences in some cause-specific outcomes.

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References:

1. JNC 7 Report. JAMA. 2003;289:2560-2572.
2. HOT study. Lancet. 1998;351:1755-1762.
3. UKPDS. BMJ. 1998;317:703-713.
4. VALUE trial. Lancet. 2004;363:2022-2031.

What is the clinical diagnosis?

Rosacea. It is a chronic inflammatory skin condition most often affecting the face, and is characterised by erythema and telangiectasia with intervening periods of papulation and pustulation. The cause of rosacea is not known. Some factors have been implicated. These include Helicobacter pylori, demodex folliculorum, alcohol intake, sun-light exposure and topical potent steroid.

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What are the features shown in the figure?

There is a symmetrical facial eruption below both eyes. It is prominent on the nose, malar areas, cutaneous lips and chin. The eruption has a background of erythema and oedema, superimposed with obvious telangiectasia on both malar areas. Inflammatory papules are remarkable but pustules not discernible.

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What are the common differential diagnoses?

The differential diagnoses include acne, seborrhoeic dermatitis, malar rash of systemic lupus erythematosus (SLE), and perioral dermatitis. Acne commonly affects teenagers. Comedones are characteristic while telangiectasia is not a feature. Seborrhoeic dermatitis shows greasy scaly erythema on central face with no obvious telangiectasia and pustules. Malar rash of SLE does not show any telangiectasia and pustules and it can be accompanied with systemic symptoms like fever and arthralgia. Perioral dermatitis shows scaly erythematous papules and vesiculopustulation. Lesions are often confined to around the mouth with a clear zone between the vermillion border and the affected skin. In some cases, perioral dermatitis is thought to be attributed by topical application of fluorinated steroid.

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What is the blood test required?

Since the patient gave a possible history of photosensitivity, it is necessary to check his antinuclear factor and/or anti-double stranded DNA antibody to exclude SLE.

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What is the treatment?

Avoidance of trigger factors like sunlight, alcohol, spicy food, hot drinks and topical steroid is required. Sunscreen can be used to reduce the amount of ultraviolet light. For mild cases with papules and pustules, topical antibiotics like metronidazole, tetracycline and erythromycin can be helpful. For more severe cases, oral tetracycline is often effective in symptom suppression but treatment is not curative. In cases where these treatments are not effective, isotretinoin often produces good clinical response but relapse may occur upon cessation of treatment. The erythema and telangiectasia can be treated with laser.

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