TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week's topics include consequences of COVID reinfection, tobacco use among America's youth, U.S. Preventive Services Task Force (USPSTF) recommendations on screening for obstructive sleep apnea, and a new agent for treatment-resistant hypertension.
Program notes:
0:31 Consequences of second COVID-19 infection
1:35 Risk elevated regardless of vaccination status
2:35 Is it the same variant?
3:35 Older and sicker individuals?
3:55 New blood pressure medicine
4:55 In addition to their existing medicines
6:00 Tobacco use among U.S. youth
7:00 Almost 14% of Alaskan or native American
8:05 State and federal interventions underway
9:00 Screening for obstructive sleep apnea in non-symptomatic individuals
10:01 Does it affect outcomes?
11:00 As many as one third of men
12:10 End
Transcript:
Elizabeth: What happens if you get reinfected with COVID?
Rick: A new blood pressure medicine -- the first in the last 15 years.
Elizabeth: Tobacco use among American youths.
Rick: Should we be screening everybody for sleep apnea?
Elizabeth: That's what we're talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I'm Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: I'm Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I'm also dean of the Paul L. Foster School of Medicine.
Elizabeth: In keeping with our normal behavior, Rick, we're going to turn straight to Nature Medicine and we're going to talk about this really huge study that was done in the VA population looking at what happens if you've already had one bout with SARS-CoV-2. What happens when you have a second one? Does this increase, decrease, or stay the same ... your risks of hospitalization, death, and sequela?
Because this is a VA population, naturally they have really very impressive ends. For people who had a single infection with COVID, they had 443,000-plus. In the reinfection cohort, which included two or more reinfections, almost 41,000. Then they had a set of non-infected controls -- over five million.
They looked at reinfection and what did it do to you with regard to your risks of death: increased it two times, your hospitalization about three times, and sequela. They looked at all the sequela including pulmonary, cardiovascular, hematologic, diabetes, gastrointestinal, all the things that we have been seeing. These all were elevated regardless of the vaccination status of the people they took a look at.
They say that this reinfection further increases your risks of death, hospitalizations, and sequela in multiple organ systems. They also looked at acute and post-acute phases, and saw that these increased risks persisted during that time.
The authors then make a case for if you haven't gotten your bivalent vaccine and if you're feeling rather casual about the whole COVID thing, maybe you really need to think about not only vaccination, but also some of the other strategies we use to decrease our risk of infection.
Rick: This is a little surprising, because we know that vaccination protects individuals from both getting infection and also from suffering from the acute and chronic sequela as well. One would presume that being infected already you would develop antibodies and memory cells that would decrease the risk in the future if you got a secondary infection.
A couple of questions. Is it the same variant across these different first and second infections? I think the answer is probably no. The other one is that those who get a second infection and are much more sick are most likely to report. Therefore there could be some reporting bias as well. What can you tell us about that?
Elizabeth: You are exactly right, and even the authors admit that these are both two limitations of this particular study. The thing that I thought I would like to have had some notion of is what comorbidities these people had. Because even when we are looking at the still relatively high rate of death, I mean we're still seeing over 300 people die a day here in the United States relative to COVID infection. They are disproportionately older and they have significant comorbidity. What is the comorbidity in this population who had had reinfections?
Rick: What we're saying is there are two things. One is there may be a reporting bias, and secondly is there may be a bias towards sicker individuals getting reinfected and therefore suffering the sequela as well. That's why I say it doesn't really jive with what we know about getting vaccinated and that protecting against both infection and chronic sequela. You would assume that a single infection would also produce very similar results.
Elizabeth: More to come, no doubt.
Which of your two would you like to turn to?
Rick: Let's talk about this new class of blood pressure medication. I said it's a new blood pressure medicine -- the first in 15 years. That probably wasn't accurate. We've had a number of different blood pressure medicines, but we haven't had a new class of antihypertensive medications approved since 2007.
That's important because elevated blood pressure is the leading global risk factor for cardiovascular disease, stroke, disability, and death. It affects 1.4 billion people worldwide. Importantly, about 10% of those persons with high blood pressure have what's called treatment-resistant hypertension -- blood pressure that's resistant to treatment with three or more medications.
This new blood pressure medicine called baxdrostat involves inhibiting the synthesis of aldosterone. The physicians and healthcare providers say, "Wait a minute. We've had other aldosterone inhibitors in the past."
The unfortunate thing is they also cross-react with the enzyme that also produces cortisol, and so they have side effects that make them oftentimes not very useful. Baxdrostat inhibits aldosterone inhibition 100 times more potently than it does cortisol. In a group of 250 patients who had treatment-resistant hypertension, when they gave 2 mg of baxdrostat compared to placebo they were able to lower the blood pressure by 11 mm of mercury. This is in phase II trials and it was a 12-week trial. We need to extend these a little bit further, but it's very promising.
Elizabeth: Talk more about this med. Is it an injectable?
Rick: It's an oral medication. You take it once a day. There are obviously side effects, but they are relatively limited. Some developed a high potassium and it went away when they took them off the medication. They were actually able to restart the medication without inducing high potassium again, especially with changing the diet a little bit.
Elizabeth: Were they seeing these impressive results with the use of baxdrostat as a single agent?
Rick: No, they continued on their current medications. They are already on three or more -- most of them were on four medications -- and they added baxdrostat to the medical regimen to get these results.
Elizabeth, let's go on to talk about another cardiovascular risk factor. Tell us a little bit more about smoking among middle and high school students.
Elizabeth: This is from Morbidity and Mortality Weekly Report (MMWR) from the CDC. It represents data from their annual National Youth Tobacco Survey (NYTS) -- in this case 2022 data -- where they take a representative sample among U.S. middle and high school students. They call middle [grades] 6 to 8 and high school 9 to 12.
The very distressing data from 2022 tells us that 11.3% of all students reported currently using any tobacco product, and that was almost 17% of high school students and almost 5% of middle school students. By far their favorite tobacco-delivery method was electronic cigarettes. That represented 14% of the high school and 3%-plus of middle school students; 3.7% of all students reported currently smoking any combustible tobacco product.
The other thing that they saw was disproportions among different groups when they broke this out. Almost 14% of Non-Hispanic American Indian or Alaska Native students smoked. 16% of those students identifying as lesbian, gay, or bisexual. Almost 17% of those who identified as transgender, over 18% of students reporting severe psychological distress, about 13% with low family affluence, and a whopping pretty close to 30% of students with low academic achievement. What it tells us, of course, is that we need to think about intervention in these groups specifically when it comes to the use of tobacco products.
Rick: The early exposure to tobacco is what leads to use of tobacco continuously as adults as well. There are ongoing efforts at the national, state, and local levels trying to minimize this and forcing the federal minimum age sale of 21 years for all tobacco products, restricting the sale of flavored tobacco products in many states and communities, raising the price of tobacco, and prohibiting public indoor use of tobacco products.
I'm particularly concerned about the disparity in Blacks, American Indians, and low-income individuals. It appeared that they have a higher exposure to tobacco advertising and also when you look at where the tobacco retail outlets are, they have a higher density in populations with low affluence as well.
Elizabeth: We have to applaud California, of course, which in this latest election said no more flavored tobacco product sales in California, so that's a good trend.
Rick: And the FDA was willing to regulate flavored cigarette or flavored tobacco products as well because these are clearly targeted toward kids.
Elizabeth: No question about it. As you know, I'm going to reflect on my goodness. Why did we ever let these things out of the barn to begin with?
Let's turn now to screening for obstructive sleep apnea.
Rick: It's estimated that the prevalence of mild obstructive sleep apnea for adults age 30 to 70 years is about 14% for men and 5% for women. That's mild. Moderate to severe is 13% for men and 6% for women. Obstructive sleep apnea -- people that either stopped breathing or decreased breathing five or more times throughout the evening -- that's associated with cardiovascular disease, cerebrovascular events, type 2 diabetes, cognitive impairment, decreased quality of life, and even motor vehicle crashes.
The question is, should we be screening asymptomatic individuals for obstructive sleep apnea? The U.S. Preventive Services Task Force looked at all the available data. There is not any convincing evidence that we should be screening asymptomatic individuals. Whenever you screen for something, you're either trying to prevent ongoing sequela or to try to address symptoms.
Well, asymptomatic individuals don't have any symptoms. We do know, however, that treatment does decrease the sleep disturbances associated with it. What we don't know is treating obstructive sleep apnea with any of the methods we have, does it somehow affect cardiovascular disease, type 2 diabetes, motor vehicle crashes, decreased quality of life, or cognitive impairment? We have no evidence that treating asymptomatic individuals does that. On the basis of that, the USPSTF is not recommending that we screen asymptomatic individuals.
Elizabeth: This, of course, begs the question of how an asymptomatic individual would ever know that they had sleep apnea to begin with, unless they were told by their bed partner.
Rick: Right. Well, there are a number of different things that are asymptomatic that we screen for, such as early detection of lung cancer in asymptomatic smokers. We're looking for aortic aneurysms that are otherwise asymptomatic in older men that smoke. In these particular individuals, as you mentioned, that don't have symptoms, screening them, is it going to make their symptoms any better?
The next question is will it prevent the other long-term sequela? Until we have data that suggests that, the USPSTF doesn't recommend doing that. They said if you just screened asymptomatic individuals, as many as a third of men and as many as 20% of women have some sleep irregularity. You'd be talking about a huge number of individuals that you may be treating without any identifiable positive results.
Elizabeth: I seem to recall that we have reported that even among people with sleep apnea that is moderate or severe, that we still haven't completed that circle where we have proven that intervention helps to reduce the cardiovascular outcomes, for example.
Rick: Exactly, Elizabeth. These are people that have known cardiovascular disease already and the treatment of sleep apnea doesn't seem to help the risk of cardiovascular disease or their risk of atrial fibrillation. Now, you can lower blood pressure very modestly by 2 or 3 mm with treatment of obstructive sleep apnea, but, again, we haven't seen any decrease in the hard endpoints that you mentioned.
Elizabeth: I'm not sure exactly what to do about that one.
On that note then, that's a look at this week's medical headlines from Texas Tech. I'm Elizabeth Tracey.
Rick: And I'm Rick Lange. Y'all listen up and make healthy choices.