Joe - I am not sure how HOT lifts the shadow off Ca blockers because
everyone in the study got them. One would need to undertake a study with a
comparison group either taking a placebo or a drug which has been shown to
be better than placebo (eg diuretics or beta blockers) and show that ca
blockers were equally or more effective in reducing CVD events. The
relatively low CVD event rates in the participants overall tells us nothing
about the drug effects. Despite the high pretreatment blood pressures,
many patients came from low CVD risk population.
Rod Jackson
>Thanks for your thoughts on a diffcult topic, Brian.
>For me, the most important message of HOT was the lifting of the shadow that
>had been cast on calcium antagonists as effective and safe agents in
>influencing the cardiovascular endpoints of hypertension.
>The question of optimum treatment is a more difficult issue. Ideally, I
>would like to be able to treat all of my hypertensive patients to a target
>diastolic of 85mm. For some, this target is straightforward; achieved with
>one or two agents, with one or two dose adjustments. For others, achieving
>the target appears to require multiple agents - I note the total of five
>different anti-hypertensives used for some in HOT. Such polypharmacy risks
>adverse drug reactions within the treatment regime, and with other drugs
>used for intercurrent illnesses. Is this significant? Does it limit the
>addaed benefit of successive layers of medication?
>The question which I would like to see answered is; what is the marginal
>benefit conferred by each successive agent beyond (say) dual therapy? My
>hypothesis is that the majority of benefit is achieved by the reduction in
>BP attained by the first one or two stages of treatment, and that further
>aggregations of drugs confer minimal extra benefit.
>This specific question has not been addressed by the HOT study, and I remain
>as ambivalent as ever about progressing beyond dual to triple, quadruple or
>quintuple treatment.
>
>Joe Neary
>66 North Brink, Wisbech, Cambs, PE13 1LN
>Tel: 01945-585884 Fax: 01945-474189
>[log in to unmask]
>
>
>>Dear List:
>> I read the paper pretty carefully. Based on intention to treat, I saw
>no
>>clinically important differences between outcomes in non-diabetic patients
>>assigned to targets of < 90, < 85, or < 80. I find nothing in the paper to
>>change the target BP for non-diabetic patients from a diastolic < 90 to
>>anything else. If i were to pick a single number for the target, I
>probably
>>would choose 85, as it provides a 5 mm Hg "cushion" that would presumably
>>maintain diastolic BP < 90 more of the time than would a BP of 89.
>>Nonetheless, I think that the conclusion of the HO"T study for non-diabetic
>>patients is clear: When initiating or increasing antihypertensive therapy,
>>setting a target diastolic BP of < 90 will provide equivalent (or better)
>>outcomes than trying to achieve a lower target BP. In the real world of
>>treating that patient, to say you should achieve a BP of 85, is wildly
>>impractical.
>> Even though it was a sub-group analysis, and I had a hard time telling
>>for sure if it was a pre-planned analysis, the absolute benefits seen in
>>diabetic patients assigned to the target of < 80 compared to those assigned
>to
>>< 85 or < 90 are impossible to ignore, especially since I am not aware of
>any
>>other direct evidence addressing treatment targets in diabetics. Thus I
>will
>>likely change my practice and make a diastolic target of < 80 for my
>diabetic
>>patients.
>> Part of EBM is looking at the evidence--not at what the authors say
>about
>>the evidence. I am eager to see what is said about the HOT study in
>Evidence-
>>Based Medicine / ACP Journal Club.
>>
>>Cheers and Best Wishes,
>>Brian
>>...................................................................
>>Brian Budenholzer, MD
>>Director, Clinical Enhancement & Development
>>Group Health Northwest
>>CC16
>>PO Box 204
>>Spokane, WA 99210-0204
>>USA
>>[log in to unmask]
>>509/ 838-9100 X 7393
>>fax: 509/ 458-0368
>>.......................................................................
>>
Dr Rodney Jackson MBChB PhD FAFPHM
Associate Professor of Epidemiology
Dpt of Community Health, School of Medicine
University of Auckland
(Grafton Mews, 52-54 Grafton Rd)
Private Bag 92019, Auckland, New Zealand
Phone: +64 (0)9-3737599 ext 6343
Fax: +64 (0)9-3737503
e-mail: [log in to unmask]
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