March 11th, 2010
Thursday, March 11 News: Blood Pressure Variability Subject of 4 Simultaneous Papers in Lancet and Lancet Neurology
Larry Husten, PHD
Interest in blood pressure variability is likely to rise considerably with the publication of four simultaneous papers on the subject by Oxford’s Peter Rothwell in the Lancet and Lancet Neurology. Rothwell points out that by relying on traditional assessment of mean systolic blood pressure, researchers have been unable to fully understand the contribution of blood pressure to stroke and coronary disease and have been baffled by some key findings in clinical trials. By adding in assessments of blood pressure variability, Rothwell maintains it may be possible to significantly improve prediction of vascular events and may have important implications for choice of therapy. The different effects of antihypertensive agents on blood pressure variability appear to explain why calcium channel blockers are more effective at reducing the risk of stroke than might be expected based on traditional blood pressure measurements and why beta-blockers are less effective. (The four papers include a Lancet cohort study, a Lancet meta-analysis, a Lancet review, and a Lancet Neurology study.)
In an accompanying comment, Bo Carlberg and Lars Hjalmar Lindholm ask whether treatment decisions should now be modified: “Not quite yet,” they conclude, “because results from clinical trials with standardized recordings and treatment care are difficult to translate into everyday practice in which patients often receive several different drugs that can change over a short time. The notion presented by Rothwell and co-workers today is, however, challenging and will raise many questions. Researchers with data from population-based cohorts or randomized trials are likely to investigate whether Rothwell’s findings can be replicated, taking other risk factors into account.”
3 Responses to “Thursday, March 11 News: Blood Pressure Variability Subject of 4 Simultaneous Papers in Lancet and Lancet Neurology”
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a new view on BP and meds for BP
Thanks, Larry, for bringing this to our attention. It does raise a lot of interesting issues about choice of meds. It also make me think more about new kinds of BP categories we can think about: low BP and stable, low BP and labile, high BP and stable, high BP and labile. It seems obvious that being in the first group is way better than being in the last group. But what about either of the 2 middle groups? Perhaps there is an age-dependent effect here, where older individuals with stiffer vessels are actually better off having stable BP, even if it means overall higher BP, in order to maximize duration of organ perfusion…
a new view on BP
This speaks to the heterogeneity of so-called primary essential hypertension, and I think to the importance of renin/aldo profiling to sort out which BP meds patients with HTN need.
If renin high – ACE or ARB, beta blockers, direct renin inhibitors
if renin low – thiazide diuretics, dihydropyridine CCBs
if renin low and aldo high – spironolactone, eplerenone, or (rarely) amiloride
if renin very low and aldo very low – Liddle’s – amiloride or (rarely) triamterene
Using this profiling approach, it is easy to control BP with a minimum of dose titrations and drug substitutions.
sorry, the periods didn’t print (this site does not allow paragraph breaks!)
If renin high – ACE or ARB, beta blockers, direct renin inhibitors. If renin low – thiazide diuretics, dihydropyridine CCBs. If renin low and aldo high – spironolactone, eplerenone, or (rarely) amiloride. If renin very low and aldo very low – Liddle’s – amiloride or (rarely) triamterene. Also need to assess for obstructive sleep apnea, non-adherence, alochol, and salt intake.