Persistent lipid abnormalities in statin-treated patients and predictors of LDL-cholesterol goal achievement in clinical practice in Europe and Canada.

BACKGROUND: The prevalence of persistent lipid abnormalities in patients receiving statins in primary and secondary care is needed to formulate recommendations for future treatment. Studies associating cardiovascular risk factors with lipid target goal achievement are lacking. DESIGN: A cross-sectional, observational study that assessed the prevalence of persistent dyslipidemia in patients treated with statins and analyzed predictors of lipid target achievement. METHODS: Serum lipid values of 22,063 statin-treated patients were studied in the context of their cardiovascular risk factors, and the potency and composition of their lipid-lowering treatment. European Society of Cardiology recommendations were used to classify patient risk, and to define LDL-cholesterol goal and normal levels for HDL-cholesterol and triglycerides. RESULTS: Overall, 48.2% of patients did not achieve the therapeutic goal for LDL-cholesterol, either as a single lipid anomaly or associated with low HDL-cholesterol, elevated triglycerides, or both. Lack of goal achievement was more prevalent among low-risk patients (55.8%) than high-risk patients (46.8%). Serum LDL-cholesterol levels were lower in high-risk patients. Predictors associated with LDL-cholesterol goal achievement were higher statin dose (odds ratio (OR): 0.35), specialist treatment (OR: 0.74), or combined lipid-lowering therapy (OR: 0.80). CONCLUSIONS: Nearly half of statin-treated patients missed their therapeutic LDL-cholesterol goal, highlighting a gap between recommendations and clinical practice. Better achievement of LDL-cholesterol therapeutic goal was found among patients at high cardiovascular risk, those on high statin doses or using combination therapy, and patients managed by specialists. Results suggest that residual dyslipidemia in statin-treated patients at low cardiovascular risk may be reduced by increasing statin dose.

Prevalence of renal artery stenosis in flash pulmonary oedema: determination using gadolinium-enhanced MRA.

PURPOSE: The primary purpose was to determine the prevalence of renal artery stenosis (RAS) in patients presenting with acute ("flash") pulmonary oedema (FPE), without identifiable cause using contrast-enhanced magnetic resonance angiography (CE-MRA) of renal arteries. A secondary goal was to correlate clinical parameters at presentation with the presence or absence of RAS. MATERIALS AND METHODS: Patients presenting with acute pulmonary oedema without identifiable cause prospectively underwent CE-MRA. >50% renal artery stenosis was considered significant. Clinical parameters (blood pressure, serum creatinine, history of hypertension/hyperlipidaemia) were compared in patients with and without RAS using an unpaired t-test. Results expressed; mean (+/-SD). RESULTS: 20 patients (4 male, 16 female, age 78.5+/-11 years) underwent CE-MRA. 9 patients (45%) had significant RAS (6 (30%) bilateral, 3 (15%) unilateral). Systolic BP was higher in patients with RAS (192+/-38 mm Hg) than those without (134+/-30 mm Hg) (p<.005). Diastolic BP was higher in patients with RAS (102+/-23 mm Hg) than those without (76+/-17 mm Hg) (p<.01). All patients with RAS and 6/11(55%) patients without RAS had a history of hypertension. No significant difference in creatinine or hyperlipidaemia history was observed. CONCLUSION: The prevalence of RAS in patients presenting with FPE is 45%. The diagnosis should be considered in patients presenting with unexplained acute pulmonary oedema, particularly if hypertensive at presentation.

A competing risks prescription refill model of compliance and persistence.

OBJECTIVES: There is evidence to suggest that noncompliant and nonpersistent behaviors have differing risk factors, clinical consequences, and responses to intervention. This has led to calls for these behaviors to be defined and measured separately to characterize medication-taking behavior comprehensively. Current prescription refill models of compliance are, however, unable to appropriately distinguish between noncompliant and nonpersistent behaviors. To address this limitation, a prescription refill model of medication-taking behavior in which noncompliance and nonpersistence are treated as competing risks is presented. METHODS: The proposed competing risks model of compliance and persistence is compared with a selection of widely applied prescription refill models of compliance and persistence using a common cohort of patients prescribed statin therapy. RESULTS: The competing risks model allows the simultaneous measurement of noncompliance and nonpersistence, the partitioning of their individual contributions to medication-taking behavior, and the estimation of noncompliance risk for patients with varying treatment persistence. The results from this model provide information about the relative and overall contributions of noncompliant and nonpersistent behaviors to medication-taking behavior. The methodology also allows an assessment of the differential influence of various risk factors on these behaviors. CONCLUSIONS: The proposed competing risks model differentiates between noncompliant and nonpersistent behaviors using prescription refill data. Results from the model provide insights into the dynamics of noncompliant and nonpersistent behaviors that have not been possible with current prescription refill methodologies.

Potentially inappropriate prescribing and cost outcomes for older people: a national population study.

AIMS: Optimization of drug prescribing in older populations is a priority due to the significant clinical and economic costs of drug-related illness. This study aimed to: (i) estimate the prevalence of potentially inappropriate prescribing (PIP) in a national Irish older population using European specific explicit prescribing criteria; (ii) investigate the association between PIP, number of drug classes, gender and age and; (iii) establish the total cost of PIP. METHODS: This was a retrospective national population study (n= 338 801) using the Health Service Executive Primary Care Reimbursement Service (HSE-PCRS) pharmacy claims database. The HSE-PCRS uses the WHO Anatomical Therapeutic Chemical (ATC) classification system and details of every drug dispensed and claimants' demographic data are available. Thirty PIP indicators (STOPP) were applied to prescription claims for those >or=70 years in Ireland in 2007. STOPP is a physiological system based screening tool of older persons' potentially inappropriate prescriptions assessing drug-drug and drug-disease interactions, dose and duration. RESULTS: In our study population PIP prevalence was 36% (121 454 claimants). The main contributors to this were: 56 560 (17%) prescribed proton pump inhibitors at maximum therapeutic dose for >8 weeks, 29 691 (9%) prescribed non-steroidal anti-inflammatories for >3 months, 17 676 (5%) prescribed long-acting benzodiazepines for >1 month and 16 201 (5%) prescribed duplicate drugs. The main determinant of PIP was polypharmacy. The likelihood of PIP increased with a significant linear and quadratic trend (P < 0.0001) with the number of drug classes.The maximum net ingredient cost of PIP was estimated to be euro38 664 640. Total PIP expenditure was estimated to be euro45 631 319, 9% of the overall expenditure on pharmaceuticals in those >or=70 years in 2007. CONCLUSIONS: The findings identify a high prevalence of PIP in Ireland with significant cost consequences.

Ventricular activation time as a marker for diastolic dysfunction in early hypertension.

BACKGROUND: A standard 12-lead electrocardiogram (ECG) is performed in all hypertensive patients, primarily to detect left ventricular hypertrophy. Echocardiographic assessment of hypertensive subjects reveals that abnormalities in diastolic function occur more commonly and earlier than increased left ventricular mass. However, ECG changes associated with diastolic dysfunction (DD) remain poorly defined; we assessed the ventricular activation time (VAT) (i.e., the time for the ventricle to depolarize) as a potential marker for DD in early hypertension. METHODS: Ninety subjects (aged 46 +/- 1.3 years; 43 men) with newly diagnosed, untreated hypertension underwent ECG and comprehensive two-dimensional echocardiography. Left ventricular DD was echocardiographically assessed using Canadian Consensus Guidelines. We compared VAT, which corresponds to the QR interval in the 12-lead ECG, with echocardiographic parameters of DD. RESULTS: VAT was prolonged in subjects with DD (46.3 +/- 0.4 vs. 39.6 +/- 0.3 ms, P < 0.01). There was a significant correlation between VAT and tissue Doppler imaging (TDI) (early diastolic velocity) e' (r = -0.53, P < 0.0001), (ratio of early and late diastolic velocities) e'/a' (r = -0.53, P < 0.0001), transmitral Doppler (TMD) (early peak filling rate, and early deceleration peak) E/A (r = -0.32, P = 0.001), and (ratio of early diastolic mitral inflow and early diastolic velocities) E/e' (r = 0.44, P < 0.0001). CONCLUSION: Prolongation of the VAT is associated with DD in patients with newly diagnosed untreated hypertension.

Centralized Pan-European survey on the under-treatment of hypercholesterolaemia (CEPHEUS): overall findings from eight countries.

BACKGROUND: Surveys evaluating plasma lipid goal attainment in patients with coronary heart disease have shown that hypercholesterolaemia is inadequately treated. Limited data account for the reasons behind this. The aim of the CEntralized Pan-European survey on tHE Under-treatment of hypercholeSterolaemia (CEPHEUS) survey was to evaluate the current use and efficacy of lipid-lowering drugs (LLD), and to identify possible patient/physician characteristics associated with failure to achieve low-density lipoprotein cholesterol (LDL-C) targets recommended by the 2003 European guidelines (Third Joint Task Force). METHODS: CEPHEUS was a European, multi-centre, cross-sectional survey conducted in eight countries and involved patients on LLD for >3 months (stable medication >6 weeks). One visit was scheduled for data collection, including fasting lipids. In all but one country, physicians and patients filled in a questionnaire about aspects of hypercholesterolaemia and treatment. RESULTS: Of the 15 199 patients recruited, 14 478 were included in the final analyses. The mean age was 63.2 years, and 45% of patients were female. Overall, 55.3% of the patients achieved their LDL-C target. In multivariate analyses, the factors identified as positive predictors for achieving LDL-C goals included normal body mass index, not smoking, not having metabolic syndrome, being on statin therapy and good treatment adherence. LIMITATIONS: The population was a selected group of subjects treated with LLD, and the results cannot be extrapolated to the general population. Patient consent was obtained, which may have selected more motivated patients and induced a positive bias. The physician and patient questionnaires were not validated, but were only used for exploratory purposes. CONCLUSION: Only 55.3% of patients using LLD achieved the LDL-C target recommended in the 2003 European guidelines.

Assessment of arterial stiffness in hypertension: comparison of oscillometric (Arteriograph), piezoelectronic (Complior) and tonometric (SphygmoCor) techniques.

BACKGROUND: Arterial stiffness, measured as aortic pulse wave velocity (PWV), and wave reflection, measured as augmentation index (AIx), are independent predictors for total and cardiovascular morbidity and mortality. The aim of this study was to compare a new device, based on oscillometric pressure curves (Arteriograph), which simultaneously measures PWV and AIx, with standard techniques for measuring PWV (Complior) and AIx (SphygmoCor) in untreated hypertensive patients. METHODS: We compared PWV and AIx measured using the Arteriograph with corresponding Complior and SphygmoCor measurements in 254 untreated hypertensive patients, age 48 +/- 14 years (mean +/- SD, range 17-85 years). RESULTS: Arteriograph PWV and AIx were closely related with Complior (r = 0.60, P < 0.001) and SphygmoCor (r = 0.89, P < 0.001), respectively. Using stepwise regression analysis, the independent determinants of Arteriograph PWV were age, mean arterial pressure, heart rate and sex (r(2) = 0.44, P < 0.0001) and for AIx were age, weight, mean arterial pressure, heart rate and sex (r(2) = 0.65, P < 0.0001). The bias between the different techniques was determined by age and sex for PWV and age, body weight, sex, heart rate and mean arterial pressure for AIx. Bland-Altman plots showed that although the techniques were closely related, the limits of agreement were wide. CONCLUSION: Although Arteriograph values and the determinants of PWV and AIx are in close agreement with corresponding parameters obtained by Complior and SphygmoCor, respectively, the techniques are not interchangeable.

A RCT evaluating the effectiveness and cost-effectiveness of academic detailing versus postal prescribing feedback in changing GP antibiotic prescribing.

PURPOSE: The aim of this study is to evaluate the effectiveness of academic detailing (AD) plus postal prescribing feedback versus postal prescribing feedback alone in reducing: (i) the overall rate of antibiotic; and (ii) proportion of second-line antibiotic prescribing. In addition, the cost-effectiveness of an outreach prescriber adviser service versus a postal prescribing feedback service was evaluated. METHODS: Volunteer general practitioner practices (n = 98) were randomized to receive prescribing feedback via postal bulletin (PB) (n = 50) or academic detailing plus postal bulletin (AD) (n = 48). Data analysis was based on the HSE-primary care reimbursement service (HSE-PCRS) prescribing database. Regression (beta) coefficients, indicating proportion change in prescribing per month, and 95% confidence intervals (CIs) are presented. The cost-effectiveness ratio was calculated from the total cost of the intervention divided by percentage change in antibiotic prescribing in AD versus PB group. RESULTS: Immediately post intervention PB (beta = -0.02, 95% CI -0.04, -0.001) and AD (beta = -0.02, 95% CI -0.03, -0.001) practices significantly decreased overall antibiotic prescribing. Second-line antibiotic prescribing was also significantly decreased by 2-3% in both groups. However, there were no significant differences in antibiotic prescribing between the randomized groups in the immediate or long-term post-intervention period. In the cost-effectiveness analysis a postal prescribing feedback service would cost euro 88 per percentage change in prescribing practice compared with euro 778 for a prescriber adviser service. CONCLUSION: Prescribing feedback significantly reduced overall and second-line antibiotic prescribing, but academic detailing was not significantly more effective than postal bulletin in changing antibiotic prescribing practice.

Blood pressure control determines improvement in diastolic dysfunction in early hypertension.

BACKGROUND: Diastolic dysfunction is common in early hypertension. We hypothesized that improvement in diastolic dysfunction is blood pressure (BP) dependent and may occur early with treatment in newly diagnosed untreated hypertensive patients. METHODS: Forty untreated hypertensive subjects (age 52 +/- 1.4 years, mean +/- s.e.m.) with diastolic dysfunction based on Canadian Consensus Guidelines, received either bendroflumethiazide 2.5 mg (1.25 mg for the first month), or candesartan 16 mg (8 mg for the first month). Left ventricular (LV) structure and function, early diastolic velocity (E') and systolic velocity, and systolic myocardial velocity (Sm) were assessed echocardiographically using M-mode, 2-dimensional, and tissue Doppler imaging (TDI) before and at 1 and 3 months following treatment. RESULTS: Antihypertensive treatment reduced BP significantly at 3 months (168 +/- 2/97 +/- 1-143 +/- 2/86 +/- 1 mm Hg, P < 0.0001). Both drugs had similar and significant effects on TDI E' which increased from 7.8 +/- 0.2 to 10 +/- 0.3 cm/s (P < 0.001). The improvement in TDI E' was independent of LV mass index (LVMI) regression but was significantly related to the improvement in Sm (r = 0.73, P < 0.0001) and the fall in systolic BP (R = 0.51, P < 0.001). Normalization of diastolic function was associated with better control of BP (130 +/- 4/81 +/- 2 mm Hg vs. 149 +/- 2/88 +/- 1 mm Hg, P < 0.05). In a stepwise regression model, reduction in systolic BP (P < 0.001) and TDI Sm (P < 0.0001) emerged as independent determinants of improvement in TDI E' with no contribution from age, gender or change in relative wall thickness (RWT) (R(2) = 0.68, P < 0.0001). CONCLUSIONS: Achieving good BP control and enhancement in systolic function determines the improvement in diastolic function in early hypertension.

Left ventricular structural and functional changes in the metabolic syndrome.

To test the hypothesis that the cardiac structural and functional abnormalities of the metabolic syndrome (MS) are independent of body mass index (BMI), 160 untreated patients (aged 47+/-1 years [mean +/- SEM], 53% male) underwent 2-dimensional echocardiography and tissue Doppler imaging and evaluation for MS. Participants with MS and controls were similar in age, BMI, and ejection fraction, but those with MS had greater left ventricular relative wall thickness (RWT) (0.43+/-0.008 vs 0.39+/-0.005, P<.001), reduced midwall fractional shortening (MFS) (13%+/-0.3% vs 14.2%+/-0.3%, P<.05), and reduced peak mitral annular velocity (Em) (9.9+/-0.5 vs 12.3+/-0.5 cm/sec, P<.01) than controls. There was a linear relationship between the number of features of MS and Em velocity (P<.001), RWT (P<.001), and MFS (P<.05). In a stepwise multiple regression analysis adjusting for likely determinants, MS was an independent predictor of Em in addition to age and nonindexed left ventricular mass. MS is associated with left ventricular concentric remodeling and reduced systolic and diastolic function independent of BMI.

Beta-blockers reduce aortic stiffness in hypertension but nebivolol, not atenolol, reduces wave reflection.

BACKGROUND: There is conflicting information with regard to the effect of beta-blockers on arterial stiffness and wave reflection. We compared a vasodilating beta-blocker, nebivolol, with atenolol. METHODS: We randomized 40 subjects with untreated hypertension (mean +/- s.e.m. systolic/diastolic blood pressure (BP) of 160 +/- 3/98 +/- 1 mm Hg, age 49 +/- 1 years) 16 of whom were women, to atenolol 50 mg or nebivolol 5 mg daily for 4 weeks. Arterial stiffness was assessed in terms of carotid-femoral pulse wave velocity (PWV, Complior) and arterial wave reflection (augmentation index (AIx) by applanation tonometry, Sphygmocor). RESULTS: Both beta-blockers produced an equal reduction in brachial BP but aortic pulse pressure (PP) was reduced to a greater extent by nebivolol (P < 0.05). PWV was decreased significantly by both therapies (nebivolol: from 11.5 +/- 0.5 to 9.9 +/- 0.5 m/s; atenolol: from 11.1 +/- 0.4 to 9.8 +/- 0.4 m/s; P < 0.01) but only nebivolol significantly reduced AIx (from 35 +/- 5 to 28 +/- 2%, P < 0.05). In addition, whereas PP amplification (PP, mm Hg) decreased with atenolol therapy (from 10 +/- 1 to 7 +/- 1, P < 0.01), it increased with nebivolol therapy (from 8 +/- 1 to 14 +/- 3, P < 0.01). Atenolol reduced heart rate to a greater extent than nebivolol did (14 +/- 3/min reduction by atenolol vs. 8 +/- 2/min reduction by nebivolol, P < 0.05). There was no difference between the two treatments in respect of the effect on transit time. CONCLUSION: The beta-blockers, atenolol and nebivolol, have a similar effect in reducing arterial stiffness in the large elastic aorta, largely secondary to BP reduction. Nebivolol, in contrast to atenolol, has an effect on small muscular arteries, increasing PP amplification and reducing wave reflection, possibly because of increased levels of nitric oxide (NO). Such ancillary properties may impart important distinct hemodynamic effects, and therefore beta-blockers cannot be regarded as a homogeneous group.

Ambulatory arterial stiffness index, pulse wave velocity and augmentation index--interchangeable or mutually exclusive measures?

BACKGROUND: The ambulatory arterial stiffness index (AASI) has been proposed as a novel measure of arterial stiffness and has been prospectively shown to predict stroke and cardiovascular death, but not cardiac death. This index has prompted considerable controversy as to whether it is a true measure of arterial stiffness. OBJECTIVE AND METHODS: The present study aimed to examine three different measures of arterial stiffness - pulse wave velocity (PWV; Complior), wave reflection [augmentation index (AIx)] and AASI - in a large hypertensive population, comparing their determinants and intercorrelations, both unadjusted and adjusted for confounders, and using Bland-Altman analysis to determine 95% confidence intervals for the ability of the AASI to predict PWV, the proposed gold standard of arterial stiffness. RESULTS: The AASI correlated univariately with both PWV and the AIx in individuals overall (r = 0.28 for PWV and r = 0.24 for AIx; both P < 0.001) and in those with untreated or treated hypertension. Adjustment for age in the current study negated entirely the positive correlation between the AASI, PWV and AIx. Additional adjustment for confounders did not significantly alter these nonsignificant relationships. Furthermore, the 95% prediction limits for the AASI to predict PWV were +/- 4.18 m/s and for the AASI to predict AIx were +/- 25.4%, suggesting that the methods would not be interchangeable in a clinical setting. Direct comparative studies would be required to establish the relative predictive strength of each measure and whether combining measures can provide additional risk prediction. Until such data become available, we propose that the measures should not be considered interchangeable.

History of gestational hypertension is associated with the metabolic syndrome and masked hypertension but not arterial stiffness in women with essential hypertension.

The underlying mechanisms of subsequent increased risk of cardiovascular disease with a history of gestational hypertension (GH) are not known. Untreated hypertensive women (n=155, age 43+/-1 years) underwent ambulatory blood pressure (BP) monitoring and assessment of aortic pulse wave velocity (PWV) and augmentation index (AIx). Despite identical clinic BP readings, the group of women with GH (n=54) had higher (P=.002) ambulatory daytime systolic BP levels and a greater number of extreme nocturnal dippers (P=.005) than the group without GH. Women with GH had higher body mass index (P=.003), greater waist circumference (P=.02), higher levels of triglycerides (P=.002), lower levels of high-density lipoprotein cholesterol (P=.004), a higher prevalence of the metabolic syndrome (P<.05) and microalbuminuria (P=.004), higher plasma renin activity (P=.03), and higher aldosterone levels (P=.01). There was no significant difference in PWV and AIx between the 2 groups. The higher prevalence of the metabolic syndrome, microalbuminuria, masked hypertension, and activation of the renin-angiotensin-aldosterone system but not arterial stiffness may explain the subsequent propensity to high BP and cardiovascular disease in women with GH.

Comparison of echocardiographic measures of left ventricular diastolic function in early hypertension.

Left ventricular (LV) diastolic dysfunction identifies patients at risk of developing heart failure and may be common in patients with hypertension. The prevalence of LV diastolic dysfunction in patients with newly diagnosed hypertension was compared using criteria provided by the Canadian Consensus, European Study Group, and American Medical Association guidelines. One hundred twenty patients with newly diagnosed untreated hypertension (mean age 46.9 +/- 2.1 years; 62 men, 58 women) with increased blood pressure (clinic >140/90 mm Hg, daytime ambulatory >135/85 mm Hg) underwent comprehensive 2-dimensional echocardiography. Transmitral inflow velocities were measured using pulse-wave Doppler with and without Valsalva's maneuver, and a comprehensive assessment of tissue Doppler velocities was performed. The prevalence of LV diastolic dysfunction varied according to criteria used. There was a high prevalence of LV diastolic dysfunction (59%; n = 71) using Canadian Consensus guidelines; 27% of patients (n = 32) had a pseudonormal pattern unmasked using Valsalva's maneuver and 32% (n = 39) had impaired relaxation at rest. Significantly fewer patients (10%; n = 12) had this diagnosis using European or American Medical Association guidelines (23%; n = 27). Using tissue Doppler imaging (early-late diastolic velocity ratio <1), the prevalence of LV diastolic dysfunction was 59% (n = 71), identical to findings using the Canadian Consensus guidelines. In conclusion, current national consensus guidelines defining LV diastolic dysfunction varied widely and underdiagnosed LV diastolic dysfunction in patients with newly diagnosed hypertension. Tissue Doppler imaging assessment is a rapidly and widely available tool that is as sensitive as the most stringent national guidelines and should be systematically incorporated into a more comprehensive assessment of LV diastolic dysfunction in this population.

Choice of first antihypertensive--are existing guidelines ignored?

AIMS: To determine adherence to hypertension guidelines in relation to age and diabetes. METHODS: The Irish HSE-PCRS prescribing database identified patients initiating antihypertensive monotherapy in 2005. Logistic regression predicted the likelihood of therapy according to guidelines. RESULTS: The odds ratio (OR) of receiving therapies according to the guideline recommendations in those <55 years vs. > or =55 years was 1.31 (95% CI 1.26, 1.37). Diabetics were more likely than nondiabetics to receive antihypertensives other than beta-adrenoceptor blockers (OR 2.97, 95% CI 2.74, 3.21). CONCLUSIONS: Our findings show some adherence to the guidelines in relation to age but selective prescribing of antihypertensives for diabetics.

Choice of first antihypertensive: simple as ABCD?

BACKGROUND: The AB/CD British Hypertension Society guidelines predict that the blood-pressure response to antihypertensive agents A (angiotensin-converting enzyme inhibitors and angiotensin receptor blockers) or B (beta blockers) drugs is better in those aged<55 years, whereas that to agents C (calcium channel blockers) or D (diuretics) agents is better in those aged>or=55 years. METHODS: We conducted a cohort study of 175 consecutive, untreated, hypertensive whites (55% men), aged 19 to 80 years and prospectively randomized to either A/B or C/D antihypertensive agents, and in whom there was no compelling reason to choose a particular drug. Blood pressure (BP) was measured using a semiautomated device (Omron 705CM, Tokyo, Japan) at baseline and 4 weeks after therapy in a single, blind fashion. RESULTS: There was no difference in baseline BP (mean+/-SEM, A/B, 163+/-2/97+/-1 v C/D, 163+/-2/95+/-1 mm Hg). Whereas the A/B drugs were more effective in younger than older patients, expressed as percentage of reduction (13%+/-1%/12%+/-1% v 8.5%+/-1%/7%+/-1%, P<.01), as absolute reduction, or by classification of mean+/-SEM blood pressure into stages of hypertension, the C/D drugs were no more effective than A/B drugs in those aged>55 years. CONCLUSIONS: The arbitrary choice of age 55 years to predict the response to antihypertensive agents in a white population is not supported by our data. A prospective, multicenter study is required to underpin guideline recommendations in relation to using age as a determinant for choice of a particular antihypertensive drug in defined hypertensive populations.

A clustered randomized trial of the effects of feedback using academic detailing compared to postal bulletin on prescribing of preventative cardiovascular therapy.

BACKGROUND: Interventions to promote prescribing of preventive therapies in patients with cardiovascular disease (CVD) or diabetes have reported variable success. OBJECTIVE: (i) To evaluate the effect of prescribing feedback on GP practice using academic detailing compared to postal bulletin on prescribing of CVD preventive therapies in patients with CVD or diabetes at 3 and 6 months post intervention and (ii) to evaluate the intervention from a GP's perspective. METHODS: Volunteer GP practices (n = 98) were randomized to receive individualized prescribing feedback via academic detailing (postal bulletin plus outreach visit) (n = 48) or postal bulletin (n = 50). The proportion of CVD or diabetic patients on statins and antiplatelet agents/warfarin pre- and post-intervention was calculated for each GP practice. Multivariate regression with a random effects model was used to compare differences between the groups adjusting for GP clustering and confounding factors. beta-Coefficients and 95% confidence intervals (CIs) are presented. RESULTS: There was a 3% increase in statin prescribing in CVD patients at 6 months post-intervention for both randomized groups, but there was no statistical difference between the groups (beta = 0.004; 95% CI = -0.01 to 0.02). Statin and antiplatelet/warfarin prescribing also increased in the diabetic population; there was no significant differences between the groups. GPs participating in the project expressed a high level of satisfaction with both interventions. CONCLUSION: Prescribing of preventive therapies increased in both randomized groups over the study period. But academic detailing did not have an additional effect on changing prescribing over the postal bulletin alone.

Primary care prescribing patterns in Ireland after the publication of large hypertension trials.

AIMS: This study assessed prescribing patterns of antihypertensive therapies (AHT) before and after the publication of the LIFE, ALLHAT and VALUE trials between 2000 and 2005. METHODS: The Irish HSE-PCRS prescribing database was used to identify those initiated any AHT. Any change 12 months before and after the trial publications was examined using a segmented regression analysis. RESULTS: There was little or no effect of any of the trials on new AHT prescribing, except for ALLHAT where there was an increase in new prescriptions for ACE inhibitors, and VALUE with a slight increase in prescriptions for calcium channel blockers. CONCLUSIONS: Our findings show that there was little or no effect of any of the three clinical trials studied on new AHT prescribing patterns in Irish general practice. Future studies should assess any underlying barriers to implementing new evidence into clinical practice.