Thanks Rod; on reflection my reading on the safety of calcium antagonists
may have been over-facile. I'll get back to reading and appraising again!
Do you have any ideas on the marginal benefits of multiple
antihypertensives?
Joe
-----Original Message-----
From: Rod Jackson <[log in to unmask]>
To: Joe Neary <[log in to unmask]>
Cc: [log in to unmask]
<[log in to unmask]>
Date: 02 September 1998 21:56
Subject: Re: Too HOT? What is the optimal diastolic blood pressure?
>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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