Treat normotensive patients after MI or stroke with antihypertensives, too
People with normal blood pressure should be given antihypertensives as part of a secondary prevention regimen in cardiovascular disease, according to Professor Richard Peto, University of Oxford.
“The key determinant is to treat high risk rather than high blood
pressure,” he
stated. If a patient has already had a heart attack or stroke then, without
any long-term medication, there is a one in two risk of another event
occurring within the next five to 10 years, regardless of whether they
have high blood pressure. When a multi-drug regimen, including aspirin
and drugs to lower blood pressure and cholesterol, is introduced this
risk is reduced to one in six.
“Once someone has had a heart attack or stroke, the recurrence
rate is substantial,” he explained. Patients with a systolic blood
pressure of 130mmHg and previous stroke or myocardial infarction are
at higher
annual risk than patients with a systolic blood pressure of 150mmHg and
no relevant disease. Professor Peto emphasised that it was a combination
of drugs that was important rather than which drugs, but he suggested
that all patients at high risk of events, even those with normal blood
pressure, should be treated with aspirin, a statin, a diuretic and an
angiotensin converting enzyme (ACE) inhibitor.
However, he was more cautious about primary prevention and stressed that
his recommendation differed from recent
suggestions for this type of
polypharmacy approach for everyone aged over 55 years (PJ, 28 June, p881).
Professor Peto was speaking during a debate about influential hypertension
trials at this year’s American Heart Association conference in
Orlando, Florida, on 10 November. During the debate, Professor John Reid,
University of Glasgow, said that there had been much discussion over
a lack of efficacy of beta-blockers in stroke prevention. However, as
yet unpublished data from an analysis conducted by the National Institute
for Clinical Excellence shows that beta-blockers are better than placebo
and not different from diuretics in stroke prevention, he said. “The
meta-analysis of beta-blockers in fatal and non-fatal stroke prevention
found a 28 per cent significant reduction in favour of beta-blockers
compared with placebo.”
Dr Bryan Williams, University of Leicester, said the question raised
by the HOPE (heart outcomes prevention evaluation) trial was whether
or not cardiovascular and stroke prevention were solely an effect of
lowering blood pressure in high risk patients or if they were specific
benefits of ACE inhibitors. He explained that HOPE was designed as a
trial of normotensive patients but that almost half had what would be
considered high blood pressure. The results for these patients influenced
the trial outcome, he said.
Head-to-head trials, including a report of the Blood Pressure Lowering
Treatment Trialists’ Collaboration published in The Lancet last
week (see p671), led Dr Williams to conclude that there is no evidence
to show that ACE inhibitors offer further advantage than lowering blood
pressure alone. “However, there are consistent findings that ACE
inhibitors are associated with less new-onset diabetes,” he said. |
