Cynthia D. Mulrow

Diltiazem was as effective as diuretics or β blockers, or both, at preventing cardiovascular mortality and morbidity

Source Citation Hansson L, Hedner T, Lund-Johansen P, et al., for the NORDIL Study Group. Randomised trial of effects of calcium antagonists compared with diuretics and β-blockers on cardiovascular...

Long acting nifedipine was as effective as hydrochlorothiazide plus amiloride for reducing mortality and morbidity in hypertension

Patients 7343 patients with hypertension were enrolled, 6575 were randomised, and 6321 (mean age 65 y, 54% women) were studied after exclusion of 9 centres because of protocol violations. Patients were required to have >1 additional CV risk factor (hypercholesterolaemia, smoking, family history of early myocardial infarction [MI], left ventricular hypertrophy or strain, coronary artery disease, or peripheral vascular disease). Follow up was 94%.

Review: Calcium antagonists lead to a higher risk for MI, congestive heart failure, and major cardiovascular events

Source Citation Pahor M, Psaty BM, Alderman MH, et al. Health outcomes associated with calcium antagonists compared with other first-line antihypertensive therapies: a meta-analysis of randomised c...

Review: isolated systolic hypertension increases mortality and morbidity in elderly people and should be treated

D a t a e x t r a c t i o n Data were extracted on study quality, patient characteristics, antihypertensive treatment, duration and length of followup, and outcomes (all-cause and cardiovascular mortality, cardiovascular complications, all strokes, and all coronary events). Strokes did not include transient ischemic attacks. Cardiovascular complications included coronary artery disease (myocardial infarction and sudden death), stroke, and vascular disorders. M a i n r e s u l t s 8 trials (15 693 patients) were included. Mean age range was 62 to 76 years, median follow-up was 3.8 years, prevalence of smoking at baseline was 16%, and 31% of participants had ≥ 1 cardiovascular complication at baseline. All-cause mortality was positively associated with systolic BP (P < 0.001) and negatively associated with diastolic BP (P = 0.05): With any given increase in systolic BP, a lower diastolic BP increased the risk for death. For each 10-mm increase in systolic BP, an increase was shown in all-cause mortality (hazard ratio [HR] 1.26, 95% CI 1.13 to 1.40), cardiovascular death (HR 1.22, CI 1.06 to 1.40), cardiovascular events (HR 1.15, CI 1.04 to 1.28), and stroke (HR 1.22, CI 1.04 to 1.40) but not coronary events (HR 1.07, CI 0.91 to 1.26). For each 5-mm Hg increase in diastolic BP, a decrease in all-cause mortality was found (HR 0.95, CI 0.89 to 1.00). With treatment, the mean reduction was 10.4 (range 6.9 to 18.2) in systolic BP and 4.1 (range 2.3 to 8.3) mm Hg in diastolic BP. An improvement in all outcomes was found when results for all trials were pooled (Table). Summary analysis showed that all outcomes improved with treatment even across subgroups based on sex, age, systolic BP, pulse pressure, previous cardiovascular complications, and smoking status.

Review: Antihypertensive drugs improve maternal outcomes in mild chronic and pregnancy-induced hypertension

To the Editor: The ACP Journal Club abstract for the review by Magee and colleagues (1) concluded that “drug treatment of mild chronic hypertension during pregnancy improves maternal outcomes.” We recently completed a systematic review addressing this topic and concluded that trial data on antihypertensive treatment for mild chronic hypertension during pregnancy are inadequate to establish beneficial or harmful effects for either the mother or the fetus. In reading the original review in BMJ on which the abstract in ACP Journal Club is based, we note that the trials addressing mild hypertension that were included in the review are not cited. We cannot assess which trials were combined to yield particular results. The primary outcomes that the authors based their conclusions on were decreased maternal hospitalizations, less severe maternal hypertension, and less additional antihypertensive treatment. The 1 trial used to make the conclusion about decreased hospitalizations was an unblinded 1979 study (2) without a placebo-controlled group that involved 58 women and used hospital admission parameters that are not relevant today (1). The outcomes of less severe hypertension and need for treatment are intermediate outcomes that were assessed in only a few trials in varying manners and that were possibly confounded by clinician opinion as trials usually were not blinded. We believe that the conclusions in the abstract and commentary are incorrect. We need large-scale trials with clinical outcomes in this area, not propagation of the unproven belief that treatment benefits mothers. Cynthia D. Mulrow, MD Baha Sibai, MD Audie L. Murphy Memorial Veterans Hospital San Antonio, Texas, USA

The cost of QALY gained was high for implantable cardioverter defibrillators compared with amiodarone for sudden cardiac death

Source Citation Owens DK, Sanders GD, Harris RA, et al. Cost-effectiveness of implantable cardioverter defibrillators relative to amiodarone for prevention of sudden cardiac death. Ann Intern Med. ...

An implanted defibrillator reduced death in patients with coronary disease at high risk for ventricular arrhythmia

Source Citation Moss AJ, Hall WJ, Cannom DS, et al., for the Multicenter Automatic Defibrillator Implantation Trial Investigators. Improved survival with an implanted defibrillator in patients with...

Moderate exercise failed to reduce blood pressure

Source Citation Blumenthal JA, Siegel WC, Appelbaum M. Failure of exercise to reduce blood pressure in patients with mild hypertension. Results of a randomized controlled trial. JAMA. 1991 Oct 16;2...