Friday, December 05, 2008


I have just posted the arguments why professionals are slow to embrace diuretics as a cheap and beneficial therapy, following the ALLHAT trial, which clearly showed that Diuretic Chlothalidone was clearly superior to Zestril and Norvasc. Even the New York Times, last week took up the issue, and basically put forward the view that perhaps professionals are not so evidence based. Well, to add to all these confusions, the results of ACCOMPLISH was published in NEJM. The results were first announced at ACC in March 2008. The Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial, a large morbidity and mortality study comparing the effects of two forms of antihypertensive combination therapies on major fatal and nonfatal cardiovascular events, is now published in the December 4, 2008 issue of the New England Journal of Medicine. This study, enrolled 11,000 patients aged 55yrs or more, treated them with ACE-I ( benazapril ) + diuretic ( hydrochlothiazide ), with ACEI ( benazapril ) + Norvasc. After 36 months of follow up, the ACEI-Norvasc arm was clearly superior in event reduction, and the trial was prematurely terminated. It is important to note that these were hypertensive with target organ damage ( the high risk group ).
I am bringing these two studies up, one after the other, to highlight the difficulties in following evidence base medicine, when data changes every week. How can any doctor keep up?. What more to consider that some trials are pharma sponsored with their obvious bias. Also, some trials used slightly different compounds, like chlothalidone in ALLHAT and Hydrochlorthiazide in ACCOMPLISH. How much difference did this make to the results?. One trial used Zestril and the other benazapril. Is that important?.
Suffice to say that in high risk hypertensives, lowering BP to target, and for me, that is 130/80mmHg or lower, as long as there are no ill-effects from the low BP, is good. There is a reasonable case being made for combo pills ( ACEI + Norvasc ) for more rapid, effective reductions in BP. My worry here is side-effects and too drastic a BP reduction.
Well, I must echo the advice of my colleagues, that perhaps the more important lesson to learn is that we must see hypertension as one parameter in the context of the global cardiovascular risk complex. The BP problem is not just a number problem. The global CVS risk must be ascertained, and treatment regimes must be instituted with these CVS risk factors in mine.
Also use diuretics, CCB, ACEI or the new ARB singularly or in combination. Get the BP down, the higher the CVS risk profile, the faster and the better.
Keeping up with all the data, spew out every week or every month, is quite a chore for busy clinicians and perhaps there is a role for blogs like this, just to say the summary of all the happenings.

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