Monday, May 25, 2009


In the 19th May 2009 issue of BMJ, Dr Law and wald of London, published a meta-analysis of 147 randomised clinical trials, involving about 958,000 patients. They were trying to find out the benefits of lowering BP and also the effects of the various anti-hypertensive drugs and regimes. Their study essentially found a few interesting conclusions. They found that giving BP control drugs to anyone suspected with hypertension had clinical benefit. All patients with hypertension, given anti-hypertensive medications had a reduction in cardiac events rates and strokes of 46% and 62% respectively. When given in combination ( either ACE-I, Beta blockers, thiazide derivatives, CCB, ARBs ), even at half the usual dose, still confer significant benefits. There goes all the difficult to remember clinical guidelines, with all their complicated charts and figures to remember.
These findings will go in-line with the thinking of some of us who believe that our normal BP should be as low as tolerable, to reduce the incidence of MACCE. It is well known that even at BP levels of 120/80mmHg ( the classical normal ), there is still a 2 fold increase in CV events. Nowadays, ( cost apart ), the new groups of anti-hypertension medications are so safe and side-effects so little, that it is only the fear of medication and the cost of medication that keeps us from routinely taking anti-hypertensive medications especially as we reach 60years of age. However, if you think of the potential benefit, of a greater then 50% reduction in incidence of strokes, the cost of medication may become acceptable.
Back in Asia, and in particular Malaysia, there need to be an intense public patient education program. Most patients are rather adverse to taking medications, unless they really feel that their lives are threatened. taking medication in an attempt to prevent a major catastrophic events do require alot of convincing.
Nonetheless, the findings of Dr Law and wald, gives further weight to the concept of trying to produce a polypill, for cardiovascular prevention. These pills will contain half normal doses of ACE-I or ARB, Beta blockers, CCB, aspirin and probably a statin in various combinations.
Will you take a polypill every morning, when you are 60years and above, in an attempt to reduce your risk of stroke and heart disease, by half? Afterall, stroke is a major catastrophy and something that we must all avoid.

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