April--2012-2:april--2012-2.qxd.qxd

Evidence Based Medicine
My patient has a lot of variability in his blood pressure measurements? Should
I be worried? What can I do which may be better?
Stroke Service and Vascular Fellowship Program, International Cerebrovascular Translational Clinical Research Training Program (Fogarty International Center and National Institute of Neurologic Disorders and Stroke), Aga Khan University Hospital, Karachi, Pakistan.
Why is this important?
risk of stroke. Ages were between 40 and 79 years (mean 63yrs) with 77% males. MRC 4396 hypertensive patients Hypertension is a strong risk factor for stroke. In between the ages of 65-74 years were included in the study.
literature most work on hypertension has been donetargeting either the Systolic blood pressure, Mean blood What were the outcomes?
pressure or Pulse pressure but the ideal value which bestmeasures the effect of anti-hypertensive drugs and predicts ASCOT-BPLA Greater blood pressure reductions outcome in terms of complications and mortality has not seen with amlodipine than atenolol attributable to decrease been identified yet. Two international trials, ASCOT-BPLA in blood pressure variability and leading to a reduction in all and MRC, have been analyzed by investigators who have cause mortality and stroke risk. Amlodipine was able to defined that blood pressure variability when measured is reduce the mean Systolic blood pressure more than atenolol able to predict the outcome and have shown that "beta (p< 0.0001) with lesser visit to visit variation (p< 0.0001) blockers" are showing a negative effect on stroke risk by and greater decrease in stroke risk than atenolol.
affecting blood pressure variability and that Calcium MRC Systolic blood pressure and all measures of channel blockers may in fact be better as they have shown within individual variation of blood pressure were higher in to decrease the stroke risk in this sub analysis by decreasing atenolol group compared with both the placebo group and the placebo group and diuretic group (p<0.0001). There was no effect on stroke risk in the first 2-3 years of the study regimens with atenolol based regimens in patients with although the early risk of stroke was reduced substantially hypertension and other vascular risk factors. MRC trial compares the effect of atenolol based and diuretic based What were the conclusions?
regimens with versus placebo in hypertensive patients Who were the participants?
antihypertensive drug classes on within individual ASCOT-BPLA 19257 patients were included in the variability of blood pressure can explain the differences in study over a period of approximately 5 years and the study was clinical efficacy consistent with findings in other reviews of halted early because of all cause mortality reduction benefit the published data. Stabilization of blood pressure is more important and the new target for drug development. responsibility of the authors and does not necessarilyrepresent the official views of the Fogarty International What does this mean for clinicians practicing
Center or the National Institutes of Health.
in Pakistan?
Recommended Reading
Hypertension is presently one in four Pakistani Dahlof B, Sever PS, Poulter NR, Wedel H, Beevers DG, Caulfieldv M, et al.
persons over the age of 45. Control of Hypertension reduces ASCOT Investigators. Prevention of cardiovascular events with an all-cause mortality, stroke, and MI and end stage renal antihypertensive regimen of amlodipine adding perindopril as required versus disease. Besides noting an absolute reduction in blood atenolol adding bendroflumethiazide as required, in the Anglo-ScandinavianCardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a pressure, we as clinicians should be looking for variability multicentrerandomised controlled trial. Lancet 2005; 366: 895-906.
in individual blood pressure and giving medications to Poulter NR, Wedel H, Dahlof B, Sever PS, et al; for the ASCOT reduce the same. Spreading out regimens, looking at investigators.Role of blood pressure and other variables in the differentialcardiovascular event rates noted in the Anglo-Scandinavian Cardiac Outcomes sustained and longer acting agents and asking patients to Trial-Blood Pressure Lowering Arm (ASCOT-BPLA).Lancet 2005; 366: 907-13.
provide more intense reading records may be a way forward Medical Research Council trial of treatment of hypertension in older adults: principal results. MRC Working Party. BMJ 1992; 304: 405-12.
MRC trial of treatment of mild hypertension: principal results. Medical Acknowledgement and Disclosure Statement:
Research Council Working Party. Br Med J (Clin Res Ed) 1985; 291: 97-104.
Webb AJS, Fischer U, Mehta Z, Rothwell PM. Effects of antihypertensive- The International Cerebrovascular Translational drug class on interindividual variation in blood pressure and risk of stroke: a Clinical Research and Training Program (ICT_CRT) at the systematic review and meta-analysis. Lancet 2010; 375: 906-15.
Williams B, Lacy PS, Thom SM, Cruickhank K, Stanton A, Collier D, et al; Aga Khan University are supported by funds from the CAFE Investigators; Anglo-Scandinavian Cardiac Outcomes Trial Award Number D43TW008660 from the Fogarty Investigators; CAFE Steering Committee and Writing Committee.
International Center and the National Institute of Differential impact of blood pressure-lowering drugs on central aorticpressure and clinical outcomes: principal results of the Conduit Artery Neurologic Disorders and Stroke. The content is solely the Function Evaluation (CAFE) study. Circulation 2006; 113: 1213-25.

Source: http://www.bfbio.com/cddata/Cardio/47%20Car.pdf