November Focus

[摘要] ‘ALLHAT's now off for ASCOT’, writes the tireless Richard Lehman (Flora Medica, page 899), and thinks we may now find ourselves shifting patients with high blood pressure from atenolol/bendroflumethiazide combination to ACE inhibitor and calcium channel blocker. But he also predicts that hypertension trials will continue forever, so huge is the current appetite for hypotensive drugs. Compared with the numbers of big trials of drugs, the review on page 875 shows that conclusive evidence on the best ways of managing the care of these patients is more difficult to find. They seem to need the kind of care that we might expect: a vigorous approach to treatment, a properly organised programme of review and reminders to those who fall out of the system. Clinicians who, at least in the past, were happy to accept blood pressures above the treatment target, will find such behaviour labelled as ‘clinical inertia’. But the study on page 838 will make everyone think again about whom we should be treating. In a review we published in September 2004, it was pointed out that the Framingham equation may overestimate risk by as much as 50%. Up to a point, Lord Copper: it may underestimate by similar amounts in the most deprived populations. The inaccuracies of the Framingham equation should not surprise, given all that has changed since the data were gathered. For instance, the rate of first myocardial infarction is falling significantly, at least in the Netherlands (page 860). The authors think this may be the result of successful prevention, but it may just be going away, as James Le Fanu suggested in the Christmas BMJ a year or two ago.

[学科分类] 卫生学