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.
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.
Facing a new international configuration after WW1The example of contacts between Czechoslovakian and French mathematical communitiesTHIS IS A VERY PRELIMINARY VERSION! Please do not pay too much attentionto the bibliography. Nobody has to be offended not to be quoted (or to be quoted. . . )! Ofcourse, we welcome every observation, complement or comment. In this paper, we are concerned with th
~ CSR & Pharmaceuticals: Big Pharma on Trial – Part 1 ~ Wayne Visser Blog Briefing, 3 June 2011 CSR & Pharmaceuticals: Big Pharma on Trial – Part 1 By Wayne Visser Let’s take a look at one of the biggest crises the world still faces: HIV/AIDS. According to the November 2009 UNAIDS report, more than 25 million people have died of AIDS since 1981. The number of peo