BMJ  2006;333:501 (2 September), doi:10.1136/bmj.333.7566.501

Letter

Spironolactone and risk of upper gastrointestinal events

Association is unproved

The first 150 words of the full text of this article appear below.

EDITOR—The study reported by Verhamme et al has several noteworthy limitations.¹ Firstly, the mortality benefit conferred by spironolactone therapy in heart failure has been shown only among patients with severe disease² and hence, as the authors acknowledged, such patients are far more likely to be prescribed this therapy than patients with, for example, relatively asymptomatic echocardiographic evidence of impaired left ventricular function. Given the fact that the authors neither stated the criteria by which they defined heart failure, an important consideration in any primary care based study,³ nor reliably adjusted for its severity in the risk model, it is plausible that the observed higher risk of upper gastrointestinal bleeding among spironolactone users is explicable by a preponderance of severe heart failure in this group.

Secondly, the study made no attempt to examine or adjust for the confounding effect of Helicobacter pylori infection, a crucial player in the pathogenesis . . . [Full text of this article]

Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE dawwas@rcseng.ac.uk

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