In-treatment HDL cholesterol levels and development of new diabetes mellitus in hypertensive patients: the LIFE Study.

AIMS: Although hypertensive patients with low baseline HDL cholesterol levels have a higher incidence of diabetes mellitus, whether changing levels of HDL over time are more strongly related to the risk of new diabetes in hypertensive patients has not been examined. METHODS: Incident diabetes mellitus was examined in relation to baseline and in-treatment HDL levels in 7485 hypertensive patients with no history of diabetes randomly assigned to losartan- or atenolol-based treatment. RESULTS: During 4.7 ± 1.2 years follow-up, 520 patients (6.9%) developed new diabetes. In univariate Cox analyses, compared with the highest quartile of HDL levels (> 1.78 mmol/l), baseline and in-treatment HDL in the lowest quartile (< 1.21 mmol/l) identified patients with > 5-fold and > 9 fold higher risks of new diabetes, respectively; patients with baseline or in-treatment HDL in the 2nd and 3rd quartiles had intermediate risk of diabetes. In multivariable Cox analyses, adjusting for randomized treatment, age, sex, race, prior anti-hypertensive therapy, baseline uric acid, serum creatinine and glucose entered as standard covariates, and in-treatment non-HDL cholesterol, Cornell product left ventricular hypertrophy, diastolic and systolic pressure, BMI, hydrochlorothiazide and statin use as time-varying covariates, the lowest quartile of in-treatment HDL remained associated with a nearly 9-fold increased risk of new diabetes (hazard ratio 8.7, 95% CI 5.0-15.2), whereas the risk of new diabetes was significantly attenuated for baseline HDL < 1.21 mmol/l (hazard ratio 3.9, 95% CI 2.8-5.4). CONCLUSIONS: Lower in-treatment HDL is more strongly associated with increased risk of new diabetes than baseline HDL level.

Reduction in albuminuria translates to reduction in cardiovascular events in hypertensive patients with left ventricular hypertrophy and diabetes.

In type 2 diabetes the degree of albuminuria is strongly related to progression of diabetic renal disease, as well as to the risk for cardiovascular complications. If normoalbuminuria is maintained, the risk of diabetic nephropathy is very low. In individuals with microalbuminuria, the rate of decline in glomerular filtration rate is closely related to the degree of albuminuria, and regression to normoalbuminuria slows down the rate of decline in renal function. Data from the LIFE-diabetes subgroup showed that levels of albuminuria well below what is usually defined as microalbuminuria, strongly predicted risk for cardiovascular complications. This indicates that when albuminuria is used as a risk predictor for cardiovascular events, so called normal values should be redefined. Traditional values for normo-micro-macroalbuminuria are primarily defined as predictors for the risk of development of diabetic nephropathy. In the LIFE-diabetes subgroup we found that reduction in albuminuria was more pronounced in losartan-based as compared with atenolol-based treatment. The benefit in favor of losartan was partly related to its major influence on albuminuria. Individuals with the highest baseline values of albuminuria had the greatest benefit in terms of reduction in cardiovascular morbidity and mortality on losartan as compared with atenolol. The level of albuminuria during treatment was closely related to the risk for cardiovascular events. We conclude that tiny amounts of albuminuria, well below traditional levels for microalbuminuria, predict cardiovascular morbidity and mortality. Reduction in albuminuria during treatment translates to reduction in cardiovascular events. Monitoring of albuminuria should be an integrated part of management of hypertension in diabetic as well as nondiabetic patients.

Alcohol consumption and cardiovascular risk in hypertensives with left ventricular hypertrophy: the LIFE study.

The Losartan Intervention For End point reduction in hypertension (LIFE) study showed superiority of losartan over atenolol for reduction of composite risk of cardiovascular death, stroke, and myocardial infarction in hypertensives with left ventricular hypertrophy. We compared hazard ratios (HR) in 4287 and 685 participants who reported intakes of 1-7 and >8 drinks/week at baseline, respectively, with those in 4216 abstainers, adjusting for gender, age, smoking, exercise, and race. Within categories, clinical baseline characteristics, numbers randomized to losartan and atenolol, and blood pressure (BP) lowering were similar on the drug regimens. Overall BP control (<140/90 mmHg) at end of follow-up was similar in the categories. Composite end point rate was lower with 1-7 (24/1000 years; HR 0.87, P<0.05) and >8 drinks/week (26/1000 years; HR 0.80, NS) than in abstainers (27/1000 years). Myocardial infarction risk was reduced in both drinking categories (HR 0.76, P<0.05 and HR 0.29, P<0.001, respectively), while stroke risk tended to increase with >8 drinks/week (HR 1.21, NS). Composite risk was significantly reduced with losartan compared to atenolol only in abstainers (HR 0.81 95% confidence interval, CI (0.68, 0.96), P<0.05), while benefits for stroke risk reduction were similar among participants consuming 1-7 drinks/week (HR 0.73, P<0.05) and abstainers (HR 0.72, P<0.01). Despite different treatment benefits, alcohol-treatment interactions were nonsignificant. In conclusion, moderate alcohol consumption does not change the marked stroke risk reduction with losartan compared to atenolol in high-risk hypertensives. Alcohol reduces the risk of myocardial infarction, while the risk of stroke tends to increase with high intake.

Accuracy of a first diagnosis of asthma in primary health care.

BACKGROUND: In a postal questionnaire study, the prevalence of asthma in southern Sweden has been found to be 5.5%. However, the register prevalence of asthma obtained from the medical records in the same municipality and age groups was found to be only 2.1%. OBJECTIVES: The aims of the study were to investigate whether the low register prevalence of asthma was caused by an underdiagnosis of asthma in primary health care and to validate a first diagnosis of asthma set by GPs in primary health care. METHODS: During a period of 3 months in 1997, all patients seeking care in the primary health care units of the municipality of Lund (population 171 877) with upper or lower airway infections, prolonged cough, allergic rhinitis, fatigue or a first positive diagnosis of asthma were recorded ( n = 3025). RESULTS: In the whole group of 3025 patients, 99 patients were found to have received a diagnosis of asthma for the first time during the study period. The diagnosis was verified in 52 of those 68 patients who attended a follow-up and examination by a respiratory physician. Among the remaining 2926 patients, 221 patients were selected randomly to constitute a control group. In this group, three patients were found to have asthma. Thus, the specificity of an asthma diagnosis set in primary health care was 0.99 [95% confidence interval (CI) 0.99-1.00] and the sensitivity was 0.59 (95% CI 0.31-0.81). CONCLUSIONS: The GPs in this study were good at excluding those who did not have asthma (specificity 99%) but less good in correctly diagnosing those who actually had current asthma (sensitivity 59%), which suggests an underdiagnosis of asthma.

The problem of uncontrolled hypertension.

It is well established that there is a continuous relationship between raised blood pressure and the risk of cardiovascular or cerebrovascular disease. Both systolic and diastolic hypertension are associated with increased risk, but systolic blood pressure appears to be a more important determinant of risk than diastolic blood pressure. Randomised controlled trials have clearly shown that lowering blood pressure results in significant reductions in cardiovascular mortality and morbidity, and hence current hypertension management guidelines recommend target blood pressures of below 140/90 mm Hg (135/85 mm Hg in the case of the WHO/ISH guidelines). Despite the clear evidence for the benefits of antihypertensive therapy, however, blood pressure is often not adequately controlled in clinical practice. Population surveys indicate that the proportion of patients achieving even conservative blood pressure targets may be only 20% or lower. A number of factors contribute to poor control of hypertension, including a focus by the physician on diastolic blood pressure, rather than the prognostically more important systolic pressure, and poor adherence to therapy by patients. Poor adherence may be largely attributable to adverse events, and there is evidence that the excellent tolerability profile of angiotensin II type 1 (AT(1))-receptor blockers may help to increase the proportion of patients remaining on therapy. AT(1)-receptor blockers could thus make a potentially important contribution to solving the problem of uncontrolled hypertension.

Prevalence of obstructive lung diseases and respiratory symptoms in relation to living environment and socio-economic group.

We wanted to test whether living environment, occupation and social position are risk factors for asthma and chronic bronchitis/emphysema (CBE). The prevalence of bronchial asthma, CBE, respiratory symptoms and smoking habits in a random sample of 12,071 adults aged 20-59 years was assessed in a postal survey with a slightly modified questionnaire previously used in central and northern Sweden (The OLIN studies). Occupation was coded according to a socio-economic classification system. Six different living environment areas were defined; city-countryside, seaside-not seaside and living close to heavy traffic-not living close to heavy traffic. Multiple logistic regression analysis (forward conditional) was applied to estimate the association between the proposed set of risk factors and self-reported obstructive lung diseases and lower respiratory symptoms controlling for age, gender and smoking. After two reminders, the response rate was 70.1% (n=8469); 33.8% of the responders were smokers. In all, 469 subjects (5.5%) stated that they had asthma and 4.6% reported CBE. Besides smoking, which was a risk for both asthma and CBE, there were different risk patterns for self-reported asthma and CBE. In the economically active population there was a tendency that CBE was more common among 'unskilled and semi-skilled workers'. This fact was further emphasized when the population was merged into the two groups 'low social position' and 'middle/high social position', with 'low social position' as a risk for CBE (OR=1.35, 95% CI=1.06-1.72). No social risk factors were identified for asthma. Living close to heavy traffic was a risk factor for asthma (OR=1.29, 95% CI=1.02-1.62) but not for CBE. Apart from this no living environmental risk factors for obstructive pulmonary diseases were identified. Asthma symptoms and long-standing cough were more common among those subjects living close to heavy traffic compared to those not living close to heavy traffic. To conclude, low social position was a risk factor for CBE and living close to heavy traffic was a risk factor for asthma.

Increased serum levels of carbohydrate-deficient transferrin in patients with chronic obstructive pulmonary disease.

OBJECTIVE: The reason that only a minority of smokers develop chronic obstructive pulmonary disease (COPD) is still largely unknown. Glycosylation defects are involved in the pathological mechanisms in cystic fibrosis (CF), where chronic progressive obstructive lung disease dominates the clinical picture. Whether defects of protein glycosylation occur in COPD has not previously been examined. Increase in carbohydrate-deficient transferrin (CDT) in serum seems to function as an indicator of general defects of N-glycosylation. Recently, one study observed high serum CDT concentrations in CF patients. We examined whether subjects with COPD also have increased serum CDT levels. METHOD AND RESULTS: A total of 131 randomly selected individuals, 45-64 years of age, underwent a medical examination, spirometry and blood tests. Serum CDT was determined using high performance liquid chromatography. In subjects diagnosed as having COPD (n = 15), multiple logistic regression analyses demonstrated a significant relationship between the diagnosis of COPD and CDT, even after all efforts were made to take the influence of age and smoking into account (odds ratio 3.16, 95% CI 1.11-8.95). Also, in subjects with COPD there was an inverse partial correlation between forced expiratory volume in 1 s (FEV1) and serum CDT (r = -0.81, p = 0.001). CONCLUSION: These results suggest that protein glycosylation defects occur in COPD and, in addition, might be involved in the pathogenetic mechanisms of the disease. It seems that further investigation of the protein glycosylation in COPD is warranted.

Relation between drug treatment and cancer in hypertensives in the Swedish Trial in Old Patients with Hypertension 2: a 5-year, prospective, randomised, controlled trial.

BACKGROUND: Is cancer related to hypertension and blood pressure? Do antihypertensive drugs promote cancer? Do antihypertensive drugs protect against cancer? We previously analysed the frequency of cardiovascular mortality and morbidity in elderly people who participated in the Swedish Trial in Old Patients with Hypertension 2 (STOP-Hypertension-2). We have also looked at the frequency of cancer in these patients. METHODS: We randomly assigned 6614 elderly patients with hypertension (mean age 76 years, median time of follow-up 5.3 years) to one of three treatment strategies: conventional drugs (diuretics or b-blockers), calcium antagonists, or ACE inhibitors. We matched the patients to the Swedish Cancer Registry and compared our findings with expected values based on age, sex, and calendar-year-specific reference frequencies for the general Swedish population. We also compared the number of cancers between the three treatment groups. FINDINGS: At baseline, 607 (9%) patients had previous malignant disease. Diagnoses were closely similar to the distribution of cancer types that might be seen in elderly patients. During follow-up, there were 625 new cases of cancer in 590 patients. The frequency of cancer did not differ significantly between the treatment strategies, including all cancers and those at individual sites. The standardised incidence ratios (SIRs) for all cancers were also close to unity: 0.92 (95% CI 0.80-1.06) for conventional drugs, 0.96 (0.83-1.10) for calcium antagonists, and 0.99 (0.86-1.13) for ACE inhibitors. INTERPRETATIONS: No difference in cancer risk was seen between patients randomly assigned to conventional drugs, calcium antagonists, or ACE inhibitors. Thus, the general message to the practising physician is that more attention should be given to getting the blood pressure down than to the risk of cancer.

Comparison of antihypertensive treatments in preventing cardiovascular events in elderly diabetic patients: results from the Swedish Trial in Old Patients with Hypertension-2. STOP Hypertension-2 Study Group.

BACKGROUND: The benefits of treating hypertension in elderly diabetic patients, in terms of achieving reductions in cardiovascular morbidity and mortality, have been documented in several recent prospective trials. There has, however, been some controversy regarding the effect of different antihypertensive drugs on the frequency of myocardial infarction in this group of patients. DESIGN: STOP Hypertension-2 was a prospective, randomized, open trial with blinded endpoint evaluation. METHODS: We studied 6614 elderly patients aged 70-84 years; 719 of them had diabetes mellitus at the start of the study (mean age 75.8 years). Patients were randomly assigned to one of three treatment strategies: conventional antihypertensive drugs (diuretics or beta-blockers), calcium antagonists, or angiotensin converting enzyme (ACE) inhibitors. RESULTS: Reduction in blood pressure was similar in the three treatment groups of diabetics. The prevention of cardiovascular mortality was also similar; the frequency of this primary endpoint did not differ significantly between the three groups. There were, however, significantly fewer (P = 0.025) myocardial infarctions during ACE inhibitor treatment (n = 17) than during calcium antagonist treatment (n = 32; relative risk 0.51, 95% confidence interval 0.28-0.92); but a (non-significant) tendency to more strokes during ACE inhibitor treatment (n = 34 compared with n = 29; relative risk 1.16, 95% confidence interval 0.71-1.91). CONCLUSION: Treatment of hypertensive diabetic patients with conventional antihypertensive drugs (diuretics, beta-blockers, or both) seemed to be as effective as treatment with newer drugs such as calcium antagonists or ACE inhibitors.

The outcome of STOP-Hypertension-2 in relation to the 1999 WHO/ISH hypertension guidelines.

The 1999 hypertension management guidelines issued by the World Health Organization and the International Society of Hypertension emphasize the importance of blood pressure reduction in the prevention of cardiovascular events. Furthermore, they conclude that the benefits of treatment are due to blood pressure lowering per se, rather than to any specific antihypertensive therapy. The results of the second Swedish Trial in Old Patients with Hypertension (STOP-Hypertension-2) are consistent with these recommendations, since in this trial angiotensin converting enzyme (ACE) inhibitors and calcium antagonists reduced blood pressure to the same extent as conventional therapy with beta-blockers and diuretics in elderly hypertensive patients, and the three treatments produced similar reductions in the risk of cardiovascular events. Furthermore, a first subgroup analysis of cardiovascular mortality showed that the three treatments seemed equally effective in diabetic patients. The STOP-Hypertension-2 data, therefore, are fully consistent with the 1999 hypertension management guidelines, and underline the advantages offered by both older and newer antihypertensive therapies.

Combined seropositivity for H. pylori and C. pneumoniae is associated with age, obesity and social factors.

BACKGROUND: Manifestations of cardiovascular disease (CVD) have been associated with chronic infection by Helicobacter pylori and Chlamydia pneumoniae both in cross-sectional and in prospective follow-up cohort studies. This association may be partly due to an increase in metabolic risk factors for CVD, secondary to low-grade inflammation caused by infections. OBJECTIVE: To investigate for subjects classified according to serology titres for infection with C. pneumoniae and H. pylori associations between seropositivity and the degree of obesity and fasting insulin levels, as well as social factors. METHODS: Using methods based on those in earlier investigations of hypertensive patients in the Dalby primary-health-care district, southern Sweden, we investigated frozen samples from serum of 310 middle-aged treated hypertensives and 288 age-matched and sex-matched normotensive controls from a defined population. The baseline examination included the measurement of weight, height and blood pressure as a mean of two office readings with the subject supine. The body mass index (BMI) was calculated as kg/m2. Fasting blood samples were drawn for measurements of levels of serum lipids, blood glucose, plasma insulin and serum lipids, including total cholesterol and triglycerides. The serology titres for H. pylori were determined by an enzyme-linked immunosorbent assay. The titres for C. pneumoniae were determined by a micro-immunofluorescence method. Self-reported factors concerning social and lifestyle backgrounds were recorded. RESULTS: The group (n = 245) of subjects with combined positive serology for H. pylori and C. pneumoniae differed from the group without any positive serology (n = 57) in age (61.6 versus 57.4 years, P < 0.05) and BMI (27.3 versus 25.8 kg/m2, P < 0.05). The seropositive group also differed in terms of fasting levels of insulin (12.7 versus 11.6 pmol/l, P < 0.05), but this difference did not remain significant after adjustment for age and BMI. We detected no intergroup difference in blood pressure and levels of glucose and lipids. Members of the group with combined seropositivity reported having a lower social-class position (educational level) than that of members of the seronegative group. CONCLUSION: Subjects with combined positive serology for H. pylori and C. pneumoniae are characterized by greater age, lower social class and higher BMI, as well as higher fasting levels of insulin than those of seronegative subjects. Obesity might be a marker not only for lower social class but also for greater than normal susceptibility to such infections.

Randomised trial of effects of calcium antagonists compared with diuretics and beta-blockers on cardiovascular morbidity and mortality in hypertension: the Nordic Diltiazem (NORDIL) study.

BACKGROUND: Calcium antagonists are a first-line treatment for hypertension. The effectiveness of diltiazem, a non-dihydropyridine calcium antagonist, in reducing cardiovascular morbidity or mortality is unclear. We compared the effects of diltiazem with that of diuretics, beta-blockers, or both on cardiovascular morbidity and mortality in hypertensive patients. METHODS: In a prospective, randomised, open, blinded endpoint study, we enrolled 10,881 patients, aged 50-74 years, at health centres in Norway and Sweden, who had diastolic blood pressure of 100 mm Hg or more. We randomly assigned patients diltiazem, or diuretics, beta-blockers, or both. The combined primary endpoint was fatal and non-fatal stroke, myocardial infarction, and other cardiovascular death. Analysis was done by intention to treat. FINDINGS: Systolic and diastolic blood pressure were lowered effectively in the diltiazem and diuretic and beta-blocker groups (reduction 20.3/18.7 vs 23.3/18.7 mm Hg; difference in systolic reduction p<0.001). A primary endpoint occurred in 403 patients in the diltiazem group and in 400 in the diuretic and beta-blocker group (16.6 vs 16.2 events per 1000 patient-years; relative risk 1.00 [95% CI 0.87-1.15], p=0.97). Fatal and non-fatal stroke occurred in 159 patients in the diltiazem group and in 196 in the diuretic and beta-blocker group (6.4 vs 7.9 events per 1000 patient-years; 0.80 [0.65-0.99], p=0.04) and fatal and non-fatal myocardial infarction in 183 and 157 patients (7.4 vs 6.3 events per 1000 patient-years; 1.16 [0.94-1.44], p=0.17). INTERPRETATION: Diltiazem was as effective as treatment based on diuretics, beta-blockers, or both in preventing the combined primary endpoint of all stroke, myocardial infarction, and other cardiovascular death.

Lowering of blood pressure and predictors of response in patients with left ventricular hypertrophy: the LIFE study. Losartan Intervention For Endpoint.

The Losartan Intervention For Endpoint (LIFE) reduction in hypertension study is a double-blind, prospective, parallel-group study comparing the effects of losartan with those of atenolol on the reduction of cardiovascular complications in patients (n = 9,194) with essential hypertension and with electrocardiographically (ECG) documented left ventricular hypertrophy (LVH). Baseline blood pressure was 174.4/97.8 mm Hg (mean), age 66.9 years, body mass index 28.0 kg/m2; 54.1% were women and 12.5% had diabetes mellitus. This population will be treated until at least 1,040 have a primary endpoint. After five scheduled visits and 12 months of follow-up, blood pressure decreased by 23.9/12.8 mm Hg to 150.5/85.1 mm Hg (target < 140/90 mm Hg). The mandatory titration level of < or = 160/95 mm Hg was reached by 72.1% of the patients. At the 12-month visit, 22.7% of all patients were taking blinded study drug alone, 44.3% were taking blinded drug plus hydrochlorothiazide (HCTZ), and 17.7% were taking blinded drugs plus HCTZ and additional drugs. Controlling for all other variables, patients in the US received more medication and had 2.4 times the odds of achieving blood pressure control than patients in the rest of the study (P < .001). Previously untreated patients (n = 2,530) had a larger initial decrease in blood pressure compared with those previously treated. Diabetics (n = 1,148) needed more medication than nondiabetics to gain blood pressure control. Only 13.9% of the patients had discontinued blinded study drug and 1.4% missed the revisit at 12 months. These data demonstrate both the successful lowering of blood pressure during 12 months of follow-up in a large cohort of patients with hypertension and LVH on ECG, but also emphasize the need for two or more drugs to control high blood pressure in most of these patients. Being previously treated and having diabetes were associated with less blood pressure response, whereas living in the US indicated better blood pressure control. It has been possible to keep most of these patients with complicated hypertension taking blinded study drug for 12 months.

Durability of improvement achieved in a clinical trial. Is compliance an issue?

BACKGROUND: The effects seen in clinical trials may not translate to actual practice situations. We examined the persistence of blood pressure effects 31 months after a clinical trial of treatment with hypotensive agents. METHODS: Nineteen previously untreated middle-aged men with hypertension had their office and ambulatory blood pressure recorded after 4 weeks of placebo treatment, 4 weeks of active treatment in a clinical trial, and 31 months of treatment in clinical practice. All recording was done by the same physician (IE). RESULTS: Mean 24-hour blood pressure was 138/92 mm Hg after 4 weeks of placebo treatment, 128/85 mm Hg after 4 weeks of active treatment in the clinical trial, and 136/87 mm Hg after a mean of 31 months of treatment in clinical practice. The corresponding blood pressure values > or =140/90 mm Hg during the daytime were 47%, 24%, and 39%, and office blood pressures were 155/101, 145/93, and 150/91 mm Hg. Individual comparison revealed that 6 of the 19 patients had higher mean 24-hour blood pressure after several months of treatment in clinical practice than after 4 weeks of active treatment in the clinical trial. CONCLUSIONS: In our study, the significantly reduced blood pressure in the clinical trial did not persist when followed up in clinical practice. At follow-up, one third of the patients had blood pressure values similar to those before active treatment. The reason for this is unclear, but inconsistent compliance may play a part in the lack of durability of the improvements. Our results indicate that effects seen in short-term clinical trials may not translate to long-term benefits in clinical practice.

Difference in blood pressure, but not in heart rate, between measurements performed at a health centre and at a hospital by one and the same physician.

BACKGROUND: Blood pressure (BP) has been found to vary between examiners, for example it is often higher when measured by a physician than by a nurse. Whether the location for the physician-measured BP is also a source of variation has, however, not been studied. Hence, we found it of interest to find out if the location used for examination was of any significance. OBJECTIVE: To explore if BP and/or heart rate measured in the same subjects by the same general practitioner in the health centre and at the hospital, differed. METHOD: Twenty-five hypertensive and 25 age-matched normotensive middle-aged men had their office BP and heart rate recorded by one and the same female general practitioner (IE) who was well known to them, at both the health centre before ambulatory BP equipment was attached to the subject and at the clinical physiological department before an exercise test. The hypertensive patients performed an exercise test and ambulatory BP was measured before and after being treated. RESULTS: The hypertensive patients' office BP was lower at the health centre than at the hospital, both when they were untreated and after they were treated. The difference (systolic/diastolic (s.d.)) was 9.4/6.0 (7.4/2.7) mm Hg (P < 0.001 for systolic and diastolic BP), when they were untreated. Corresponding figures when they were treated were 5.4/4.0 (9.4/4.7) mm Hg, a significant difference in diastolic BP (P < 0.001). The normotensive subjects also had a lower office BP at the health centre than at the hospital. The difference (systolic/diastolic (s.d. ) was 1.8/5.3 (7.0/5.0) mm Hg (P < 0.001 for diastolic BP). Heart rate did not differ between recordings in the health centre and in the hospital, either in the hypertensives or in the normotensives. CONCLUSION: Office BP differed significantly between measurements performed in the health centre and at the hospital. Hence, being examined at a hospital seemed to be a stronger stimuli in most patients than to be examined in a health centre. When diagnosing or evaluating treatment in hypertension, this may have implications. Journal of Human Hypertension (2000) 14, 355-358

Evaluation of a computer-based decision support system for treatment of hypertension with drugs: retrospective, nonintervention testing of cost and guideline adherence.

OBJECTIVE: To evaluate a computerized decision support system (DSS) for drug treatment of hypertension, regarding quality, safety, and cost compared to actual antihypertensive drug treatment. DESIGN: The medical profiles of 338 hypertensive patients treated with drugs against hypertension were processed by the DSS. The drug treatment proposed by the system was then compared to actual treatment given by their physician. SETTING: Four health centres in the county of Västerbotten, in Sweden. SUBJECTS: A list of hypertensive patients was extracted from the computerized medical records of each health centre and every fifth patient's medical profile was assessed by the system. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Drug used, drug used in relation to certain major diseases such as diabetes mellitus, asthma, ischaemic heart disease (IHD), and previous myocardial infarction. Adherence to hypertension guidelines, safety, and cost. RESULTS: The DSS suggested significantly more thiazides and significantly fewer calcium antagonists than the physicians had prescribed, with a total cost reduction of 33-40%, depending on doses chosen. The DSS drug profile was more adherent to guidelines in patients with major complicating diseases, suggesting an improvement in treatment quality for these patients by the DSS. CONCLUSION: The DSS which fully implements current guidelines may improve the quality of antihypertensive treatment, concurrently leading to a considerable reduction in drug costs.