hypertension

Mild Hypertension - An approach to using evidence in the decision making process

The key pooled outcomes from these 5 trials reveal the following: Would you take the pill?
1. Total mortality, RR 0.95 [0.71 - 1.11] - no real difference between taking or not aking.
2. Total serious adverse events were not reported in any of the trials.
3. Total cardiovascular events (fatal and non-fatal strokes plus fatal and non-fatal coronary heart disease) were reduced from 4.0% to 3.2%, RR 0.81 [0.71 - 0.92], ARR 0.8%,
Number Needed to Treat is 125 people for 5 years for one person to benefit.
4. Withdrawals due to adverse events, RR 4.8 [4.2 - 5.6], ARI 9%, NNH 11 for 5 years.

You now feel you are in a position to explain the benefits and harms to your patient.

Treatment of Hypertension

Aiming for a target diastolic BP of lower than 90 mm Hg provides no therapeutic advantage for most hypertensive patients.

The two groups with lower bp might be expected to have fewer cardiovascular events but this was not seen

ALLHAT STUDY

• Total mortality, coronary heart disease and end-stage renal disease are similar for first-line thiazides (diuretic), CCBs (Calcium channel blockers) and ACEIs (Angiotensin-Converting Enzyme).

• Heart failure is increased with first-line CCBs as compared to thiazides or ACEIs.

• Stroke is reduced with first-line thiazides as compared to ACEIs.

• BP control and tolerability are better with first-line thiazides as compared to ACEIs.

• Cost is substantially less for thiazides as compared to beta-blockers, ACEIs, CCBs, alpha blockers, and angiotensin receptor blockers.

Drugs of Choice in the Treatment of Hypertension

After review of the long term hypertension studies, including the epidemiologic and randomized placebo controlled drug trials, certain clinically important facts stand out:

• Risk of cardiovascular events correlates better with systolic than diastolic blood pressure.(1)

• Risk correlates better with blood pressures taken outside the doctor's office than with office blood pressures.(2)

• Blood pressure consistently decreases with placebo treatment (10/8 mm Hg).(3)

• The average additional blood pressure fall in the active treatment group is modest (11/6 mm Hg).(3), (4)

• The average blood pressure fall with treatment in trials using low doses of just one drug (7-9.5/46.5mm Hg) (5), (6) is similar to that obtained from an overview of trials using high doses of multiple drugs (11/6 mm Hg).(3), (4)

These facts suggest the following ways to assist in managing your patients with hypertension:

• Put more emphasis on systolic and home blood pressures when making treatment decisions.

• Appreciate that some of the blood pressure lowering effect seen in the office is due to the placebo effect. In other words, no matter what you are prescribing, it is likely to appear efficacious.

• Realize that pushing the dose seldom improves the antihypertensive effect. Likewise, the dose can frequently be lowered in patients receiving high doses of antihypertensive drugs without changing the antihypertensive effect.

Can blood pressure be lowered by a change in diet? Evidence from the DASH trials

Substantial BP lowering can be achieved by a reduced dietary sodium intake, the DASH diet, or a combination of the two. This approach is applicable to those patients consuming an average North American diet who are motivated to make a change.

Atenolol

If you on this maybe you'd be better off on something else