Friday, December 23, 2011


Very seldom do we see trial results after 22 years. well, in hypertension, we are seeing. Dr John Kortis and colleagues of New Brunswick, USA reported their SHEP results after 22 years of follow-up. The results is ( in my opinion ), not so wonderful.
SHEP ( systolic Hypertension in the Elderly Program ), began in 1985 when they enrolled 4,700 elderly hypertensives aged average 72years. To half they gave chlorthalidone and the other half placebo. If the treatment arm did not achieve target, they were allowed to add atenolol. After 4.5 years of follow-up, when the trial concluded, of course the treatment arm did better ( less MACCE basically ). Thereafter, all the patients were given chlorthalidone, and treated.
After 22 years, when they tracked the survivors ( 60% had died ). For the rest who were still alive, they found that for every month of treatment during the trial, they lived 1 day longer. Meaning that the treatment arm lived an average of 105 days longer from all cause mortality, and there were 185 fewer CV deaths.
These numbers are not great. But I suppose, the survivors have already, during the trial period less strokes and CV events. So they have benefited, and treating elderly hypertensives, I suppose is mainly to prevent strokes. We now know that treated elderly hypertensives does not prolong life very much ( 1 day for every month of drug therapy ).
The other thing that I did not understand was that, chlothalidone is obviously a better diuretic for treatment benefit, compared to hydrochlothiazide and yet all the big pharmas, use hydrochlothiazide as their diuretic when they made their combo pills like Co-Diovan, Co-Approvel, Micardis Plus, etc. I always felt that it would have been better to have used Diovan plus chlorthalidone, or irbesartan plus chlorthalidone, etc.
I suppose the other comments worth noting is that this trail is one trial where the investigators outlive the patients. Usually after 22 years, the investigators would have also expired.
Anyway, now we know that in the elderly, treatment only confers minimal survival benefit. We have to think that there is better quality of life and a more productive life. That is why we treat them.

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