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BMJ No 7101 Volume 315 This week in brief Saturday 19 July 1997 HRT offers women no protection against cardiovascular disease ß Blockers and diuretics should still be first for hypertension Inpatient mortality from heart attack has not changed in 10 years Fundholding improves cost containment HRT offers women no protection against cardiovascular disease The popularity of postmenopausal hormone therapy is increasing, largely because of its claimed benefits on cardiovascular diseases. Only one small trial has studied such health effects, so Hemminki and McPherson (p 149) examined pooled data of reported adverse effects from clinical trials that studied other outcomes. From 22 trials with 4124 women the odds ratios for comparison of the women taking hormones with those who were not was 1.64 (95% confidence interval 0.67 to 5.04) for all cardiovascular events. These results do not support the notion that hormone therapy prevents cardiovascular events. ß Blockers and diuretics should still be first for hypertension Angiotensin converting enzyme inhibitors and calcium channel blockers have been recommended as initial monotherapy for hypertension, but few studies have compared them with established ß blockers and diuretics. Philipp et al (p 154) evaluated the effectiveness and tolerability of these four treatments over one year in a double blind, controlled study in over 900 patients with uncomplicated hypertension. After eight weeks the ß blocker (atenolol) was more successful in reducing blood pressure (64% of subjects reached target pressure) than the angiotensin converting enzyme inhibitor (enalapril, 50%), the diuretic (hydrochlorothiazide, 45%), or the calcium channel blocker (nitrendipine, 45%). After one year atenolol was still more effective than hydrochlorothiazide and nitrendipine but not enalapril. Elderly patients responded better to hydrochlorothiazide and nitrendipine and women to enalapril, although in each subgroup the highest rate of response was still with atenolol. The results indicate no advantage for the new classes of drugs. Inpatient mortality from heart attack has not changed in 10 years Important changes have taken place in the management of acute myocardial infarction over the past 15 years. Brown et al (p 159) reviewed trends in the management of patients admitted with acute myocardial infarction in a single district during defined periods over 10 years. They showed an increasing but suboptimal uptake of aspirin, ß blockade, and thrombolysis. There were still delays in admission, with 15% of patients admitted too late for thrombolysis. Logistic regression analysis of death rates, allowing for age and sex, showed that the odds ratio for death from myocardial infarction remained unchanged. Fundholding improves cost containment The British government introduced fundholding into general practice as a means of containing costs. Rafferty et al studied the prescribing patterns of almost all practices in Northern Ireland from 1989 to 1996 and found that initial fundholders were more effective at containing costs than non-fundholding practices (p 166). The rate of generic prescribing rose by an average of 13% among fundholders in their first year. Nevertheless, by the third year the costs of first wave fundholders rose by the same amount as those of non-fundholders, suggesting that the scope and incentive for further saving is greatly reduced. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline