Hypertension - Therapy with diuretics and beta blockers decreases the risk of stroke
Clinical Bottom Line
Treatment of isolated systolic hypertension with diuretics and/or beta blockers decreases the risk of stroke in the elderly.
SHEP Co-operative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA 1991;265:3255-64.
In a patient with hypertension, will therapy with diuretics decrease the risk of stroke and death?
"stroke" and "hypertension" in Best Evidence
- Double-blinded concealed randomised controlled trial with intention-to-treat.
- patients = 60 years with isolated systolic hypertension
- Control group (N = 2371; 2371 analysed): placebos
Experimental group (N = 2365; 2365 analysed):
4 consecutive steps
- chlorthalidone12.5 mg/d;
- increase to chlorthalidone 25 mg/d;
- addition of atenolol 25mg/d or reserpine 0.05 mg/d;
- increase to atenolol 50mg/d or reserpine 0.1 mg/d.
- Goal of therapy was SBP < 160 mm Hg and a reduction in SBP of at least 20 mmHg. Any patient with sustained SBP > 220 mmHg or DBP > 90 mmHg was given active treatment
|Outcome||Time to Outcome||CER||EER||RRR||ARR||NNT|
|95% Confidence Intervals||15% to 54%||0.107 to 0.036||28 to 100|
|95% Confidence Intervals||-32% to 5%||-0.029 to 0.005||
NNT = 209 to INF
NNH = 35 to INF
- decreased risk of nonfatal MI or coronary heart disease death with treatment (RR 0.73 [0.57 to 0.94])
- only enrolled 1% of the patients that were screened - included the very well elderly and therefore each clinician must assess each patient's individual baseline risk and individualise the NNT using this estimate
- at 5 years, 90% of the study group and 44% of controls were on active treatment and therefore the study likely underestimates the benefits of therapy since an intention to treat analysis was done
- was there some unblinding because of the need for some patients(more often the ones receiving diuretics) to receive potassium supplements