High blood pressure in males in late adolescence associated with increased risk of major cardiovascular events later in life

Embargoed for release until 5:00 p.m. ET on Monday 25 September 2023
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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
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1. High blood pressure in males in late adolescence associated with increased risk of major cardiovascular events later in life

Risk gradually increased beginning with a blood pressure of 120/80 mm Hg

Early attention to blood pressure and intervention for hypertension may be critical to reducing later cardiovascular events

Abstract: https://www.acpjournals.org/doi/10.7326/M23-0112 
FREE Summary: https://www.acpjournals.org/doi/10.7326/P23-0007 

URL goes live when the embargo lifts
A study of more than one million Swedish men followed for up to 50 years found that higher blood pressure (BP) at age 18 was associated with an increased risk for major cardiovascular events later in life, including heart failure, heart attacks, strokes, and mortality. The risk for major cardiac events became elevated beginning at a BP of 120/80 mm Hg. According to the researchers, early intervention for hypertension may be critical to reducing later cardiovascular events. The findings are published in Annals of Internal Medicine.

Hypertension is the leading cause of cardiovascular disease (CVD) and premature death in the world. The association between BP level and cardiovascular outcomes has been extensively studied in middle-aged and older persons, but not enough is known about the association between BP in adolescence and future cardiovascular events.

Researchers from Umeå University and Uppsala University studied 1,366,519 men enlisted in the Swedish military between 1969 and 1997 to measure the association between high blood pressure in adolescence and risk for cardiovascular events in adulthood. The participants’ baseline BP was measured during conscription. Using the American College of Cardiology/American Heart Association guidelines for classifying BP elevation, the baseline BP was classified as elevated at 120 to 129/<80 mm Hg. Based on these measurements, 28.8 percent of participants had an elevated baseline BP and 53.7 percent had a hypertensive baseline BP. Over up to 50 years follow up, the researchers found a substantial and gradual absolute risk increase across BP categories for all major cardiovascular outcomes in adulthood. One in 10 adolescents with combined stage 2 hypertension would have a major cardiovascular event before retirement, whereas those with BP below 120/80mmHg would not. According to the authors, the results of this study highlight the possibility of identifying persons with increased cardiovascular risk in late adolescence, enabling early intervention to prevent CVD. This possibility should encourage practitioners to measure BP in adolescents, which is not done routinely.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author Helene Rietz, MD, please email helene.rietz@umu.se.

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2. Once-weekly insulin icodec with dosing guide app showed superior HbA1c reduction versus once-daily insulin in phase 3a trial

Abstract: https://www.acpjournals.org/doi/10.7326/M23-1288
URL goes live when the embargo lifts

In the Phase 3a ONWARDS 5 randomized trial, once-weekly insulin icodec titrated with a dosing guide app demonstrated superior reduction in HbA1c levels and similarly low hypoglycemia rates compared with once-daily insulin. The findings are published in Annals of Internal Medicine.

Missed insulin injections and inadequate dose titration of daily basal insulins can lead to suboptimal glycemic control in persons with type 2 diabetes. Once-weekly insulin icodec is a basal insulin analogue that is in development and is aimed at reducing treatment burden. A once-weekly dosing schedule could improve treatment adherence, satisfaction, and glycemic control.

The ONWARDS 5 trial randomly assigned 1,085 insulin-naïve adults with type 2 diabetes in seven countries to either weekly icodec titrated with a dosing guide app (icodec with app) or once-daily basal insulin (OD analogs) dosed per standard practice. The two groups were compared for effectiveness and safety. The authors found that participants using icodec with app experienced a greater HbA1c reduction, treatment satisfaction, and adherence compared to participants using the OD insulin. According to the authors, the use of icodec with a dosing guide app could conceivably address several challenges seen in everyday practice, including inadequate dose titration and nonadherence to prescribed treatment regimens for patients with diabetes.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author Harpreet S. Bajaj, MD, MPH, please contact harpreet.bajaj@LMC.CA.

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3. Almost 4 in 10 adults with type 1 diabetes are not diagnosed until after age 30

Abstract: https://www.acpjournals.org/doi/10.7326/M23-1707 

URL goes live when the embargo lifts

A brief research report including more than 900 adults with type 1 diabetes found that 37 percent, or nearly 4 in 10 participants, were diagnosed with type 1 diabetes after age 30. Age of diagnosis was higher for men and racial minority adults. The findings are published in Annals of Internal Medicine.

Adult-onset type 1 diabetes is frequently misdiagnosed as type 2 diabetes, leading to inappropriate care.

Emerging data suggest that up to 62% of type 1 diabetes cases develop after age 20 years. However, prior studies have been done in selected clinical populations. Clarifying the burden of adult-onset type 1 diabetes in the general population may help reduce misdiagnosis.

Researcher from Johns Hopkins Bloomberg School of Public Health analyzed data from the 2016 to 2022 cycles of the National Health Interview Survey (NHIS) to characterize the age distribution of type 1 diabetes diagnosis in the United States, overall and according to demographic and clinical characteristics. Based on data for 947 patients with type 1 diabetes, the authors found that the peak diagnosis age was approximately 15 years, and the median age of diagnosis was 24 years. The authors also found that the age of diagnosis was older in men than women, and for racial/ethnic minority adults compared to non-Hispanic White adults. The authors report that overall, 37 percent of participants reported a diagnosis after age 30 years. According to the authors, tools integrating clinical measures and biomarkers may improve the accuracy of diagnosis for these patients.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author Elizabeth Selvin, PhD, MPH, please contact eselvin@jhu.edu.

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4. New ACP paper addresses ethical issues in physician fundraising from ‘grateful patients’

Abstract: https://www.acpjournals.org/doi/10.7326/M23-1691 

URL goes live when the embargo lifts

In a new position paper, the American College of Physicians (ACP) addresses the question of “grateful patient” fundraising, stating that physicians should not engage in, or be asked or expected to participate in, fundraising solicitation of their patients or patient families. The position paper is published in Annals of Internal Medicine.

Philanthropic support remains very important to the financial health and implementation of the mission of hospitals and health systems in the U.S. A newer approach to fundraising, often called “grateful patient” fundraising, however, raises ethical concerns when physicians and their patients (or patient families) are involved. 

Questions have been raised about the physician’s role in such activities and whether physicians should be asking patients or families for financial contributions and whether involvement by physicians affects relationships, creating “tension between their roles as caregiver and fundraiser, potentially undermining the trust at the heart of the doctor-patient relationship.”

Additional ethical concerns include pressure on patients to donate and the effects of this on the patient-physician relationship; potential expectations of donor patients for treatment that is not indicated or to receive preferential care; justice and fairness issues; disclosure and use of confidential patient information for nontreatment purposes; and conflicts of interest. Using the patient-physician relationship and knowledge of the patient’s medical history and clinical status, personal information, and financial circumstances are some of the reasons development and administrative officials might see physicians as strong potential fundraisers; but use of this information is among the reasons why physician involvement is ethically problematic. 

Developed by ACP’s Ethics, Professionalism and Human Rights Committee, ACP believes physicians should not engage in, or be asked to participate in fundraising or financial solicitation of their patients and suggests that:

• Participation by physicians in health care fundraising should be guided by the best interests of patients and by the need to establish and maintain trust in the patient-physician relationship. Patients or family members inquiring about charitable donations should be directed to the institution’s administrators. Other activities that do not involve payments by their patients but constitute fundraising include speaking at events, attending galas, giving public talks related to the physician’s area of expertise or research, encouraging philanthropy by colleagues, which can be ethically acceptable.  
• Physicians have a duty to protect patient privacy and confidentiality and should not reveal or use patient information for fundraising purposes. Maintaining confidentiality and respecting patient privacy are core ethical responsibilities for physicians. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule was modified in 2013 to expand access to and use of protected health information (PHI) by health care fundraisers. ACP opposes the use and disclosure of PHI for fundraising purposes under the modification.

• Physicians should not be asked or expected to participate in fundraising solicitation of their patients or patient families as a condition of employment, or a part of an incentive program.  Employed physicians may be expected to lend their professional reputation to promote campaigns without control over usage, for example perpetual use of their photograph taken for a promotional campaign.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with someone from ACP, please contact Andy Hachadorian at ahachadorian@acponline.org.

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