Guidelines from the British Hypertension Society
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《英国医生杂志》
EDITOR—The optimal lipid targets are a total cholesterol concentration of < 4.0 mmol/l or a reduction of 25% from baseline. The percentage reduction approach is needed for patients starting statin treatment for secondary prevention or because of their high cardiovascular risk but whose total cholesterol value is already close to the target. For example, for such patients starting statin treatment with a total cholesterol of 4.1 mmol/l, lowering cholesterol to 3.9 mmol/l is clearly not sufficient and a 25% reduction is required.
Many people in the United Kingdom are indeed unaware that they have a raised blood pressure and are therefore at increased risk. Most will develop more serious hypertension over time. How will that be detected without a programme of monitoring? It may not be cost effective for Green to do it, but somebody should. The "real world of general practice" cannot meet the challenges of modern health care, so changes in service delivery are needed.
The ALLHAT study is just one of many reviewed by the BHS.1 People 55 years of age or over were recruited. BHS-IV guidelines recommend diuretics as one of two evidence based options for initial treatment for people aged 55 years and above. Below this age other drugs have been proved to be more effective at lowering blood pressure2—the key objective of treatment. Hence the AB/CD algorithm provides a simple template for selecting the first and subsequent drugs to facilitate and encourage reaching blood pressure targets on the basis of age and ethnic group. We have suggested an audit standard of total cholesterol < 5.0 mmol/l and an optimal target of 4 mmol/l. The former reflects established guidance, the latter increasing awareness, endorsed by clinical trials, that lower achieved cholesterol values further reduce cardiovascular risk.3
ASCOT-LLA was a primary prevention study that recruited patients with an average 10 year cardiovascular risk similar to the 20% risk threshold suggested by the guidelines for primary prevention.4 In this study the addition of a statin for people with well controlled blood pressure (138/80 mm Hg) clearly showed an additional 36% reduction in fatal and non-fatal coronary events and a 27% reduction in stroke. This fully justifies considering statin treatment as a complementary means of further reducing cardiovascular risk in people with treated hypertension whose baseline 10 year cardiovascular disease risk is estimated to be 20%, irrespective of baseline cholesterol values.
Most older people have high blood pressure—75% of UK adults over the age of 65 years ( 140/90 mm Hg). However, BHS-IV is more conservative than other international guidelines. It does not recommend treatment for all people with stage 1 (mild) hypertension (blood pressure 140-159/90-99 mm Hg). Instead, for primary prevention, it recommends treating only patients at high risk of cardiovascular disease (10 year risk 20%). The cost effectiveness of treating hypertension was recently analysed by the National Institute for Clinical Excellence (NICE) as part of its guideline development process. Treating hypertension alone was shown to be one of the most cost effective medical interventions thus far evaluated—hence the incorporation of hypertension as one of the key targets in the new general medical services contract.
That a specific patient will benefit from a particular intervention is not certain, only that reducing blood pressure and cholesterol will on average reduce cardiovascular disease risk. The size of absolute benefit depends on the absolute risk and relative risk reduction. The former can be estimated using the risk tables in the guidelines and the latter is known. Extensive trial evidence is available to confirm that treatment benefits outweigh any harm across the treatment range recommended.
Many doctors have been reluctant to acknowledge the success of healthcare policies directed at reducing the risk of cardiovascular disease in the United Kingdom. Primary care has played a central part. Service redesign, coupled with effective implementation of current guidance, will continue to improve the nation's cardiovascular health.
Bryan Williams, guideline working party chairman
Department of Cardiovascular Sciences, Clinical Sciences Building, Leicester Royal Infirmary, University of Leicester, Leicester bw17@leicester.ac.uk
The full reply is available on bmj.com
See editorial by Campbell
On behalf of the British Hypertension Society
Additional authors are: guideline working party members—Neil R Poulter, International Centre for Circulatory Health, Imperial College London and St Mary's Hospital, London; Morris J Brown, Clinical Pharmacology Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge; Mark Davis, general practitioner, Moorfield House Surgery, Garforth, Leeds; Gordon T McInnes, Section of Clinical Pharmacology and Stroke Medicine, Division of Cardiovascular and Medical Sciences, Gardiner Institute, Western Infirmary, University of Glasgow, Glasgow; John F Potter, Ageing and Stroke Medicine Section, Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, Leicester; Peter S Sever, International Centre for Circulatory Health, Imperial College London & St Mary's Hospital, London. British Hypertension Society member—Simon McG Thom, International Centre for Circulatory Health, Imperial College London and St Mary's Hospital, London.
Competing interests: All authors have received honorariums from a number of pharmaceutical companies for lectures and consultancy, and research grant support for clinical trials from the pharmaceutical industry.
References
The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the antihypertensive and lipid lowering treatment to prevent heart attack trial (ALLHAT). JAMA 2002;288: 2981-97.
Dickerson JE, Hingorani AD, Ashby MJ, Palmer CP, Brown MJ. Optimisation of antihypertensive treatment by crossover rotation of four major classes. Lancet 1999;353: 2008-13.
Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Be R, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. New Eng J Med 2004;350: 1495-504.
Sever PS, Dahlof B, Poulter NR, Wedel H, Beevers G, Caulfield M; ASCOT investigators. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo Scandinavian cardiac outcomes trial-lipid lowering arm (ASCOT-LLA): A multicentre randomised controlled trial. Lancet 2003;361: 1149-58.
Many people in the United Kingdom are indeed unaware that they have a raised blood pressure and are therefore at increased risk. Most will develop more serious hypertension over time. How will that be detected without a programme of monitoring? It may not be cost effective for Green to do it, but somebody should. The "real world of general practice" cannot meet the challenges of modern health care, so changes in service delivery are needed.
The ALLHAT study is just one of many reviewed by the BHS.1 People 55 years of age or over were recruited. BHS-IV guidelines recommend diuretics as one of two evidence based options for initial treatment for people aged 55 years and above. Below this age other drugs have been proved to be more effective at lowering blood pressure2—the key objective of treatment. Hence the AB/CD algorithm provides a simple template for selecting the first and subsequent drugs to facilitate and encourage reaching blood pressure targets on the basis of age and ethnic group. We have suggested an audit standard of total cholesterol < 5.0 mmol/l and an optimal target of 4 mmol/l. The former reflects established guidance, the latter increasing awareness, endorsed by clinical trials, that lower achieved cholesterol values further reduce cardiovascular risk.3
ASCOT-LLA was a primary prevention study that recruited patients with an average 10 year cardiovascular risk similar to the 20% risk threshold suggested by the guidelines for primary prevention.4 In this study the addition of a statin for people with well controlled blood pressure (138/80 mm Hg) clearly showed an additional 36% reduction in fatal and non-fatal coronary events and a 27% reduction in stroke. This fully justifies considering statin treatment as a complementary means of further reducing cardiovascular risk in people with treated hypertension whose baseline 10 year cardiovascular disease risk is estimated to be 20%, irrespective of baseline cholesterol values.
Most older people have high blood pressure—75% of UK adults over the age of 65 years ( 140/90 mm Hg). However, BHS-IV is more conservative than other international guidelines. It does not recommend treatment for all people with stage 1 (mild) hypertension (blood pressure 140-159/90-99 mm Hg). Instead, for primary prevention, it recommends treating only patients at high risk of cardiovascular disease (10 year risk 20%). The cost effectiveness of treating hypertension was recently analysed by the National Institute for Clinical Excellence (NICE) as part of its guideline development process. Treating hypertension alone was shown to be one of the most cost effective medical interventions thus far evaluated—hence the incorporation of hypertension as one of the key targets in the new general medical services contract.
That a specific patient will benefit from a particular intervention is not certain, only that reducing blood pressure and cholesterol will on average reduce cardiovascular disease risk. The size of absolute benefit depends on the absolute risk and relative risk reduction. The former can be estimated using the risk tables in the guidelines and the latter is known. Extensive trial evidence is available to confirm that treatment benefits outweigh any harm across the treatment range recommended.
Many doctors have been reluctant to acknowledge the success of healthcare policies directed at reducing the risk of cardiovascular disease in the United Kingdom. Primary care has played a central part. Service redesign, coupled with effective implementation of current guidance, will continue to improve the nation's cardiovascular health.
Bryan Williams, guideline working party chairman
Department of Cardiovascular Sciences, Clinical Sciences Building, Leicester Royal Infirmary, University of Leicester, Leicester bw17@leicester.ac.uk
The full reply is available on bmj.com
See editorial by Campbell
On behalf of the British Hypertension Society
Additional authors are: guideline working party members—Neil R Poulter, International Centre for Circulatory Health, Imperial College London and St Mary's Hospital, London; Morris J Brown, Clinical Pharmacology Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge; Mark Davis, general practitioner, Moorfield House Surgery, Garforth, Leeds; Gordon T McInnes, Section of Clinical Pharmacology and Stroke Medicine, Division of Cardiovascular and Medical Sciences, Gardiner Institute, Western Infirmary, University of Glasgow, Glasgow; John F Potter, Ageing and Stroke Medicine Section, Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, Leicester; Peter S Sever, International Centre for Circulatory Health, Imperial College London & St Mary's Hospital, London. British Hypertension Society member—Simon McG Thom, International Centre for Circulatory Health, Imperial College London and St Mary's Hospital, London.
Competing interests: All authors have received honorariums from a number of pharmaceutical companies for lectures and consultancy, and research grant support for clinical trials from the pharmaceutical industry.
References
The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the antihypertensive and lipid lowering treatment to prevent heart attack trial (ALLHAT). JAMA 2002;288: 2981-97.
Dickerson JE, Hingorani AD, Ashby MJ, Palmer CP, Brown MJ. Optimisation of antihypertensive treatment by crossover rotation of four major classes. Lancet 1999;353: 2008-13.
Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Be R, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. New Eng J Med 2004;350: 1495-504.
Sever PS, Dahlof B, Poulter NR, Wedel H, Beevers G, Caulfield M; ASCOT investigators. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo Scandinavian cardiac outcomes trial-lipid lowering arm (ASCOT-LLA): A multicentre randomised controlled trial. Lancet 2003;361: 1149-58.