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RESEARCH: Blood Pressure Lowering Treatment Trialists’ Collaboration Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials BMJ 2008; 336: 1121-1123 [Abstract] [Full text]

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drug choice and efficacy may depend on the aims of treatment

oscar,m jolobe   (17 May 2008)

No difference between different antihypertensives in reducing cardiovascular mortality?

Ian KC Fok   (20 May 2008)

drug choice and efficacy may depend on the aims of treatment 17 May 2008
oscar,m jolobe, retired geriatrician manchester medical society, c/o john rylands university library, oxford road, manchester M13 9PP Send response to journal: Re: drug choice and efficacy may depend on the aims of treatment	To paraphrase Bryan Williams, the choice of different regimens to lower blood pressure(BP) in older and younger people depends on whether the aim is to prevent the consequences of established cardiovascular damage or whether the aim is to regress early damage(1). By the time elastic fibres have been sufficiently damaged to cause arterial stiffness regression of vascular damage is no longer possible, and this becomes self -perpetuating because, from then onwards, a progressive rise in blood pressure becomes inevitable(2). This is the point of no return where meta- analysis will show "no clear difference between age groups in the effects of lowering blood pressure or any difference between the effects of the drug classes on major cardiovascular events"(3). Regression of abnormal parameters of cardiovascular intergrity, before they become self- perpetuating, requires a different approach and, arguably, different drug choices. The first approach is to identify abnormal parameters of cardiovascular intergrity when BP is still in the prehypertensive phase, the latter characterised by systolic BP 120-139 mm Hg and/or diastolic BP 80-89 mm Hg.The second is to include angiotensin receptor blockers(ARB's) in the therapeutic armamentarium. The parameters of cardiovascular integrity chosen in one study included small and large artery elasticity, carotid intimal-media thickness, integrity of retinal vasculature, blood pressure at rest and on exercise, features of the 12 lead electrocardiogram, left ventricular mass index(LMI), plasma B-type natriuretic peptide, and microalbuminuria. Patients with prehypertension were enrolled into the study only if they showed abnormalities in 6 or more of the above parameters. As a result of 6 months treatment, patients receiving ARB's showed significantly(p=0.03) greater reduction in the number of abnormal parameters than counterparts treated with other antihypertensive agents. Small artery elasticity increased by 57% in response to ARB's(p < 0.0001)but only by 9%(p=0.38) in the non ARB subgroup. LMI decreasesd significantly(p < 0.05) only in those who had received ARB treatment for 6-12 months(4). This study also makes it easier to apply, more selectively, the results of an earlier study which showed that ARB treatment could retard the transition from prehypertension to hypertension(5). Instead of offering drug treatment to all subjects with prehypertension, only those with abnormal parameters of cardiovascular integrity could be targetted, and those who do not have abnormal parameters could be managed solely with lifestyle advice. References (1)Williams B The year in hypertension Journal of the American College of Cardiology 2008:51:1803-17 (2)Najjar SS., Scuteri A., Shetty V et al Pulse wave velocity is an independent predictor of the longitudinal increase in systolic blood pressure and incident hypertension in the Baltimore Longitudinal Study of Aging Journal of the American College of Cardiology 2008:51:1377-83 (3)Blood Pressure Lowering Treatment Trialists Collaboration Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger people: meta-analysis of randomised trials British Medical Journal 2008:336:1121-3 (4) Duprez DA., Florea ND., Jones K., Cohn JN Beneficial effects of valsartan in asymptomatic individuals with vascular or cardiac abnormalities. The DETECTIV Pilot Study Journal of the American College of Cardiology 2007:50:835-9 (5) Julius S., Nesbitt SD., Egan BM et al Feasibility of treating prehypertension with an angiotensin receptor blocker New England Journal of Medicine 2006:354:1685-97 Competing interests: None declared
No difference between different antihypertensives in reducing cardiovascular mortality? 20 May 2008
Ian KC Fok, Medical Registrar Prince of Wales Hospital, Sydney 2010 Send response to journal: Re: No difference between different antihypertensives in reducing cardiovascular mortality?	I am surprised to learn from this meta-analysis that there are no differences between the effects of the drug classes on major cardiovascular events (P<0.24). Given that the different drug classes would have different relative potencies in reducing the blood pressure & that it is to be argued that the major benefit of antihypertensives in decreasing mortality is by decreasing the blood pressure; the conclusion is not immediately intuitive. A possible improvement on the study might have been to compare between the age groups & the classes of medications as to which age group & with which antihypertensives are the target blood pressure reduction goals most likely to be achieved. Woe be a drug company. Competing interests: None declared