The Difficult task of Finding the Best Antihypertensive Agent
There are a few silent epidemics in medicine, and heart failure certainly is one of them. There are good reasons to care about it: End-stage HF is more deadly than most cancers, and only recently has the idea of HF with prerved ejection fraction been transformed into being accepted as diastolic heart failure. Now diastolic HF is interesting for 2 reasons: (1) it is more common in women—a subgroup notoriously underdiagnod, undertreated, and underreprented in clinical trials; and (2) from a global perspective, one of the major risk factors for its development is hypertension and the ensuing hypertensive heart dia. Hypertension, however, does not only lead to diastolic HF but, from a global perspective, it reprents the major risk factors for the development of HF as such.1
In this issue of the 英语教案网Archives, Sciarretta et al prent the results from a Bayesian network meta-analysis with respect to possible differences of individual antihypertensive strategies regarding the prevention of HF. They report on 223 313 individuals included in 26 antihypertensive trials. Of the, 186 378 individuals (83.5%) had an established diagnosis
of arterial hypertension on inclusion in the respective trials, and a total of 8554individuals (3.8%) were diagnod as having HF during the cour of their respective study. The main result is that diuretics and ACE inhibitors/ARBs were the most effective treatment and should therefore be considered first-line therapy with respect to HF prevention.
There are veral interesting aspects of this meta-analysis. First, the most reassuring probably is the fact that—with the exception of α-and β-blockers—all active treatment strategies were effective in preventing HF when compared with placebo. This is good news becau prevention of HF is not the only goal of any antihypertensive treatment and therefore not the only influence on our choice of drug. Also, this corroborates the finding of a previous meta-analysis2 in which, with the exception of β-blockers, all other drug class showed comparable reduction of left ventricular mass.
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英语学习官网Second, subanalys did not show significant alterations of the findings when examining x- or age-dependent effects. This finding is in line with tho of other large-scale analys3, 4沈阳英语学校 with respect to the confounders. Interestingly, in this study the adva
ntage of diuretics over ACE inhibitors was smaller the higher the percentage of women and elderly patients, as was the difference between CCBs and RAS inhibitors in studies with younger and/or predominantly male patients. Again, this is good news becau in clinical practice it should help to diminish any potential treatment has with respect to age and/or x.
Third, and most interestingly, following the network diagram, CCBs, ACE inhibitors, and ARBs could be tested directly against all of the other drug class, whereas diuretics specifically could not. Now it is one of the virtues of network meta-analys to be able to get past this limitation, but at least some of the evidence in favor of diuretics is only indirect.
juniorschoolSo, are we to abandon β-blockers as an antihypertensive option altogether and head toward u of diuretics? Before jumping to this conclusion, we should remember that especially in meta-analys the choice of subgroup and, most important, the choice of end point will influence our results. In a recent meta-analysis by Law et al,5 β-blockers, fo
r example, did not significantly reduce the overall incidence of coronary heart dia events. However, in persons with preexisting coronary heart dia there was even a special protective effect. More important, there was significant heterogeneity with respect to HF prevention in that β-blockers without cardiolective properties lacked any protective effect whereas βmultiply是什么意思-blockers with cardiolective properties did not. Unfortunately, the prent study did not differentiate the individual properties.
句子翻译在线Furthermore, this picture changes of one looks at stroke or mortality as end points. Calcium channel blockers em to be slightly more effective than the rest in preventing stroke.5,6 This ems plausible becau they also best reduce interindividual variation in blood pressure--a measure that indicates risk of stroke independently of effects on mean blood pressure.7 Having said this, it should be noted that the level of blood pressure reduction is important with respect to composite cardiovascular end points, and larger reductions in blood pressure em to lead to larger reductions in risk.6
影视动漫培训aestheticallyOverall, there ems to be no major difference between the individual drug class as to
total or cardiovascular dia mortality,6,8 and this holds true even when looking at high-risk(diabetic) patients.伴音9 Then again, the risk of renal cell carcinoma ems to be lower with diuretic therapy compared with other treatments, with the effect being less pronounced in women than in men. 10 In the light of the results by Sciarretta et al, we should therefore concentrate once again on the true center of medical attention--our patient--and we should weigh our choice of first-line treatment against comorbidities, coexisting treatment, and personal preferences regarding risk and quality of life.
