A regimen of calcium channel blocker with or without an angiotensin-converting enzyme inhibitor (ACEI) is more effective than an older regimen of beta-blocker with or without a diuretic in terms of blood pressure control and reduction of coronary heart disease events in hypertensive patients with relatively low cholesterol levels.

True. This hypothesis was proven in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT). Amlodipine and perindopril were used against atenolol and bendroflumethiazide. The trial was discontinued early because of the efficacy of the amlodipine/perindopril arm. In this arm, several prespecified secondary endpoints were significantly lower, including all-cause mortality, all coronary events, all cardiovascular events and procedures, stroke and cardiovascular mortality when compared with the beta-blocker arm. New onset diabetes was also lower in this treatment arm.

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Among patients with stable coronary heart disease, a LDL target of 75mg/dl will reduce more cardiovascular events when compared with a target of 100mg/dl.

True. This was proven in the Treating to New Targets Study (TNT). Among patients with stable ischemic heart disease, treatment with high dose (80mg) atorvastatin to achieve an LDL below 100mg/dl was associated with a reduction in the primary endpoint of major cardiovascular events at 5 years including non-fatal myocardial infarction and stroke when compared with treatment with low dose (10mg). Among the secondary endpoints, major coronary events and hospitalization for congestive heart failure was also lowered in the aggressive treatment arm. However, persistent abnormal liver function tests were more frequent in the 80mg group compared with the 10mg group, indicating that close monitoring is necessary in patients receiving this high dose.

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COX-2 inhibitors are safe for pain management following coronary artery bypass grafting surgery.

False. In the COX-2 inhibitors After Cardiac Surgery trial, among patients undergoing CABG with cardiopulmonary bypass, short term treatment with COX-2 inhibitor for pain management was associated with an increase in overall adverse events and in cardiovascular adverse events. It should also be noted that in other recent trials in patients receiving other selective COX-2 inhibitors for the prevention of colorectal cancer, a higher incidence of serious arterial thromboembolic events was also noted, raising the concerns on the safety of this group of drugs in patients with cardiovascular disease.

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Treatment with vitamin E as compared with placebo is associated with a reduction in primary cardiovascular events in women.

False. In the Women's Health Study: Vitamin E in Primary Prevention, treatment with 600 IU on alternate days was not associated with a difference in the primary endpoint of major cardiovascular event reduction at a mean 10 year follow up when compared with placebo. These findings, along with data from the earlier Heart Protection Study, do not support the use of vitamin E for prevention of cardiovascular disease.

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What are the clinical differential diagnoses?

The clinical differential diagnoses are alopecia areata, tinea capitis and trichotillomania. Trichotillomania (compulsive hair pulling) is a neurotic practice of plucking one's own hair from the scalp or eyelashes, usually as a mechanism to relieve stress or tension.

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What bedside examination should be performed?

The scalp should be examined for "exclamation mark hair" which was characteristic of active alopecia areata. A Wood's lamp examination helps to detect the fluorescence of tinea capitis caused by some fungi such as Microsporum canis. Microscopic examination of hair sample for fungal elements should also be performed as appropriate. These examinations were negative in this patient. A "hair growth window" test will help to diagnose trichotillomania: shave a 3x3 cm² area in the involved part of the scalp weekly. Hair inside this area will be too short for plucking and the hair will recover and regain normal density several weeks later.

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What are the characteristic features of scalp hair seen in this condition?

Focal bizarre patches of alopecia on scalp of dominant hand side with remaining short stubby broken hair are features of trichotillomania.

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Name one complication that may be seen in this condition.

Gastric trichobezoar due to ingestion of the pulled hair may be seen in some cases. If severe, it may produce intestinal obstruction.

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What is the definite treatment?

The impulsive reactive nature of this condition should be explained and reassurance given to the patient and parents. In mild acute cases, the condition can be self limiting. In chronic cases, psychiatrist assessment with behavioral modification, psychotherapy and use of selective serotonin reuptake inhibitor may be required.

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