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
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>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
>.......................................................................
>
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