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Update in Cardiology

Elliot Rapaport, MD
[+] Article and Author Information

From San Francisco General Hospital and University of California, San Francisco, San Francisco, California.


Potential Financial Conflicts of Interest:Consultancies: Sanofi, Bristol-Myers Squibb, Pfizer Inc.; Honoraria: Sanofi, Bristol-Myers Squibb, AstraZeneca. Dr. Rapaport has also provided expert testimony in malpractice cases for some law firms in Utah.

Requests for Single Reprints: Elliot Rapaport, MD, Cardiology Division, Room 5G1, San Francisco General Hospital, 1001 Potrero Street, San Francisco, CA 94110.


Ann Intern Med. 2006;145(8):618-625. doi:10.7326/0003-4819-145-8-200610170-00011
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This Update in Cardiology features 13 articles published in 2005. They were chosen from among thousands because of their particular interest or importance to the field, focusing on hypertension, diabetes and cardiovascular disease, acute myocardial infarction, and heart failure. Changes to clinical practice emerging from these articles are shown in the Table .

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Do we need a change in hypertension guidelines?
Posted on October 31, 2006
Mohsen S Eledrisi
King Abdulaziz National Guard Medical Center- Alahsa, Saudi Arabia
Conflict of Interest: None Declared

In the "Update in cardiology" article (1), Rapaport draws conclusions from the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA) (2) and recommends to "consider using amlodipine as first -line antihypertensive in patients with ³ 3 other cardiovascular risk factors". This should be interpreted carefully. ASCOT-BPLA found no difference in its primary outcome and the reported benefits were observed in secondary endpoints. In addition, several issues were raised about the design of the trial. First is the choice of a β-blocker as a comparator for first-line therapy versus amlodipine. Ever since the medical research council trial (3) showed that atenolol was not better than placebo in preventing cardiovascular disease, there have been reservations about the use of β-blockers as first-line antihypertensive therapy. Second, the dose of bendroflumethiazide (1.25 to 2.5 mg/day) was lower than the 10 mg/day used in previous trials that showed a benefit. This, in part, may account for the difference in blood pressure between the groups favoring the amlodipine group. Third, the diuretic was added to only 56.6 % of patients during the first year and about two-third of them during the following years. Lastly, the choice of an angiotensin-converting enzyme (ACE) inhibitor as an add-on therapy for the amlodipine group could have positively influenced the results since ACE inhibitors were shown to lower cardiovascular mortality and morbidity among high-risk patients (4).

Thiazide diuretics were found to be superior to calcium channel blockers and ACE inhibitors in lowering rates of cardiovascular disease among a large number of patients with diverse racial backgrounds (5,6). ASCOT-BPLA confirms the existing data that β-blockers should not be used as first-line antihypertensive therapy unless there are compelling indications. However, it does not change the current evidence that thiazide diuretics should be the first-line therapy for most patients with hypertension (7,8).

References

1. Rapaport E. Update in cardiology. Ann Intern Med. 2006;145:618- 625.

2. Dahlöf B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895-806.

3. Medical Research Council trial of treatment of hypertension in older adults: principal results. MRC Working Party. BMJ. 1992;304:405-12.

4. Danchin N, Cucherat M, Thuillez C, et al. Angiotensin-converting enzyme inhibitors in patients with coronary artery disease and absence of heart failure or left ventricular systolic dysfunction: an overview of long-term randomized controlled trials. Arch Intern Med. 2006;166:787-796.

5. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic. JAMA. 2002;288:2981-2997.

6. Wright JT Jr, Dunn JK, Cutler JA, et al. ALLHAT Collaborative Research Group. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA. 2005;293:1595-1608.

7. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252.

8. Psaty BM, Lumley T, Furberg CD, et al. Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA 2003;289:2534-2544.

Conflict of Interest:

None declared

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