Editor's Choice | This Week in BMJ | Press releases
BMJ No 7101 Volume 315 Papers - Abstracts Saturday 19 July 1997
Impact of postmenopausal hormone therapy on cardiovascular events
and cancer: pooled data from clinical trials
Impact of postmenopausal hormone therapy on cardiovascular events and cancer: pooled data from clinical trialsElina Hemminki, Klim McPherson AbstractObjective: To examine the incidence of cardiovascular diseases and cancer from published clinical trials that studied other outcomes of postmenopausal hormone therapy as some surveys have suggested that it may decrease the incidence of cardiovascular diseases and increase the incidence of hormone dependent cancers.Design: Trials that compared hormone therapy with placebo, no therapy, or vitamins and minerals in comparable groups of postmenopausal women and reported cardiovascular or cancer outcomes were searched from the literature. Subjects: 22 trials with 4,124 women were identified. In each group, the numbers of women with cardiovascular and cancer events were summed and divided by the numbers of women originally allocated to the groups. Results: Data on cardiovascular events and cancer were usually given incidentally, either as a reason for dropping out of a study or in a list of adverse effects. The calculated odds ratios for women taking hormones versus those not taking hormones was 1.39 (95% confidence interval 0.48 to 3.95) for cardiovascular events without pulmonary embolus and deep vein thrombosis and 1.64 (0.65 to 4.18) with them. It is unlikely that such results would have occurred if the true odds ratio were 0.7 or less. For cancers, the numbers of reported events were too low for a useful conclusion. Conclusions: The results of these pooled data do not support the notion that postmenopausal hormone therapy prevents cardiovascular events. National Research and Development Centre
for Welfare and Health, London School of Hygiene and Tropical Medicine, Correspondence to: Professor Hemminki.
Randomised, double blind, multicentre comparison of hydrochlorothiazide, atenolol, nitrendipine, and enalapril in antihypertensive treatment: results of the HANE studyThomas Philipp, Manfred Anlauf, Armin Distler, Heinrich Holzgreve, Joerg Michaelis, Stefan Wellek on behalf of the HANE Trial Research Group AbstractObjective: To compare the effectiveness and tolerability of hydrochlorothiazide, atenolol, nitrendipine, and enalapril in patients with mild to moderate hypertension.Design: Randomised multicentre trial over 48 weeks with double blind comparison of treatments. Setting: 48 centres in four countries. Patients: 868 patients with essential hypertension (diastolic blood pressure 95-120 mm Hg) Interventions: Initial treatment (step 1) consisted of 12.5 mg hydrochlorothiazide (n=215), 25 mg atenolol (n=215), 10 mg nitrendipine (n=218), or 5 mg enalapril (n=220) once daily. If diastolic blood pressure was not reduced to <90 mm Hg within four weeks, doses were increased to 25 mg, 50 mg, 20 mg, 10 mg, respectively, once daily (step 2) and after two more weeks to twice daily (step 3). The eight week titration phase was followed by an additional 40 weeks for patients who had reached the target diastolic pressure. Main outcome measure: Blood pressure by means of an automatic device with repeated measurements. Results: After eight weeks the response rate for atenolol (63.7%) was significantly higher than for enalapril (50.0%), hydrochlorothiazide (44.7%), or nitrendipine (44.5%). After one year atenolol was still more effective (48.0%) than hydrochlorothiazide (35.4%) and nitrendipine (32.9%), but not significantly better than enalapril (42.7%). The treatment related dropout rate was higher (P<0.001) in the nitrendipine group (n=28). Conclusions: There is no evidence of superiority for antihypertensive effectiveness or tolerability of the "new" classes of antihypertensives (calcium channel blockers and angiotensin converting enzyme inhibitors). As these drugs are now widely used as treatment of first choice, our results further emphasise the need for studies confirming that they also reduce morbidity and mortality, as has been shown for diuretics and ß blockers. Zentrum für Innere Medizin, Zentralkrankenhaus
Reinkenheide, Medizinische
Klinik and Poliklinik, Medizinische Poliklinik,
University of Munich, D-80336 Munich, Germany
Institut fur
Medizinische Statistik, Abteilung Biostatistik, Correspondence to: Dr Philipp.
Inpatient deaths from acute myocardial infarction, 1982-92: analysis of data in the Nottingham heart attack registerNigel Brown, Tracey Young, David Gray, Allan M Skene, John R Hampton AbstractObjective: To assess longitudinal trends in admissions, management, and inpatient mortality from acute myocardial infarction over 10 years.Design: Retrospective analysis based on the Nottingham heart attack register. Setting: Two district general hospitals serving a defined urban and rural population. Subjects: All patients admitted with a confirmed acute myocardial infarction during 1982-4 and 1989-92 (excluding 1991, when data were not collected). Main outcome measures: Numbers of patients, background characteristics, time from onset of symptoms to admission, ward of admission, treatment, and inpatient mortality. Results: Admissions with acute myocardial infarction increased from 719 cases in 1982 to 960 in 1992. The mean age increased from 62.1 years to 66.6 years (P<0.001), the duration of stay fell from 8.7 days to 7.2 days (P<0.001), and the proportion of patients aged 75 years and over admitted to a coronary care unit increased significantly from 29.1% to 61.2%. A higher proportion of patients were admitted to hospital within 6 hours of onset of their symptoms in 1989-92 than in 1982-4, but 15% were still admitted after the time window for thrombolysis. Use of ß blockers increased threefold between 1982 and 1992, aspirin was used in over 70% of patients after 1989, and thrombolytic use increased 1.3-fold between 1989 and 1992. Age and sex adjusted odds ratios for inpatient mortality remained unchanged over the study period. Conclusions: Despite an increasing uptake of the "proved" treatments, inpatient mortality from myocardial infarction did not change between 1982 and 1992. Division of Cardiovascular Medicine, British Heart Foundation Cardiovascular Statistics
Unit, Correspondence to: Dr Brown.
How has fundholding in Northern Ireland affected prescribing patterns? A longitudinal studyThérèse Rafferty, Keith Wilson-Davis, Hugh McGavock AbstractObjective: To compare prescribing patterns in general practices before and after the introduction of fundholding in April 1993 to determine whether fundholding changed prescribing patterns among practices that joined the scheme.Design: Analysis of prescribing data from the Drug Utilisation Research Unit's database for all practices in Northern Ireland during April 1989 to March 1996. Setting: Northern Ireland. Subjects: 23 first wave fundholders, 34 second wave fundholders, 9 third wave fundholders, and 268 non-fundholders. Main outcome measures: Prescribing costs per 1000 patients, prescription items per 1,000 patients, average cost per item, and rate of generic prescribing. Results: Prescribing costs and frequency increased in all groups throughout the study. Among the fundholders the rate of increase in costs after fundholding was significantly lower than among non-fundholders. The rate of increase in cost per item fell, coinciding with a significant increase in the rate of generic prescribing. However, with regard to first wave fundholders, their yearly increase in costs in their third year as fundholders (1995-6) was similar to that of the non-fundholders. The earlier practices that joined the scheme seemed to differ in some important respects from those that joined later. Conclusions: After fundholders joined the fundholding scheme their patterns of prescribing changed compared with those of non-fundholders: the rate of increase in costs fell and there was a significant rise in the rate of generic prescribing.
Drug Utilisation Research Unit, Correspondence to: Miss Rafferty.
Home | Current contents | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline
|