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RESEARCH: Jonathan Mant, Richard J McManus, and Rachel Hare Applicability to primary care of national clinical guidelines on blood pressure lowering for people with stroke: cross sectional study BMJ 2006; 332: 635-637 [Abstract] [Full text]

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Stroke and the global public health challenge; the clock is ticking away…………….

George I. Varughese, Sharmistha R. Chowdhury (Specialist Registrar in Diabetes, Endocrinology & General Internal Medicine - All Wales Higher Training Programme)   (1 March 2006)

Blood pressure lowering and stroke

Elliot Epstein, Anil Kumar   (20 March 2006)

More research or different research?

Moyez Jiwa   (28 March 2006)

National Stroke Guidance is applicable to primary care

Wayne Sunman   (7 April 2006)

Stroke and the global public health challenge; the clock is ticking away……………. 1 March 2006
George I. Varughese, Specialist Registrar in Diabetes, Endocrinology & General Internal Medicine University Hospital of North Staffordshire, Stoke-on-Trent ST4 6QG, Sharmistha R. Chowdhury (Specialist Registrar in Diabetes, Endocrinology & General Internal Medicine - All Wales Higher Training Programme) Send response to journal: Re: Stroke and the global public health challenge; the clock is ticking away…………….	The study by Mant et al [1] provides more insights in to the missed opportunities for prevention. Despite the fact that the practices selected were active in research and the blood pressure [BP] control may have been better than in the U.K. as a whole, for 80% of the patients systolic BP was above the targets set by the British Hypertension Society [1]. There were also notable paucities in aggressive combination therapy and this has particular inference, given the huge burden of hypertension on stroke and cardiovascular disease - 21400 stroke deaths and 41400 ischemic heart disease deaths (approximately 42,800 strokes and 82,800 ischaemic heart diseases saved, making a total of 125,600 events saved) each year in the U.K. [2]. Thus, the emphasis by most BP management guidelines calling attention to the need for more aggressive treatment targets [3] cannot be stressed any further, given the disability-adjusted life-years and mortality associated with the global burden of hypertension [4]. Nevertheless, one recent report [5] on primary care physicians choices of antihypertensive and lipid-lowering therapy for subjects with type 2 diabetes diagnosed with hypertension found considerable variation between practices that were not explained by adjusting for age, sex, prevalent coronary heart disease or study year; whilst trends in drug utilisation were consistent with the evolving evidence base but there was still wide variations in drug utilisation between practices. The question therefore is not ‘Do we lower blood pressure in stroke patients?’ …. but ‘How do we best lower blood pressure?’ Hence, current available guidelines should continue to be used as evidence base, and perhaps we should not be ageist, but rather take a more belligerent approach in trying to tackle the major public health challenge [4]. [1] Mant J, McManus RJ, Hare R. Applicability to primary care of national clinical guidelines on blood pressure lowering for people with stroke: cross sectional study BMJ, doi:10.1136/bmj.38758.600116.AE (published 24 February 2006) [2] He FJ, MacGregor GA. Cost of poor pressure control in the UK: 62000 unnecessary deaths per year. J Human Hypertens 2003; 17: 455-457. [3] Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF et al; British Hypertension Society. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004; 18(3): 139-185. [4] Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet 2005; 365: 217–223. [5] Gulliford MC, Charlton J, Latinovic R. Trends in antihypertensive and lipid-lowering therapy in subjects with type II diabetes: clinical effectiveness or clinical discretion? J Hum Hypertens 2005; 19(2):111-117. Competing interests: None declared
Blood pressure lowering and stroke 20 March 2006
Elliot Epstein, Consultant Physician Walsall Manor Hospital NHS Trust. Moat Road,. Walsall. West Midlands. WS2 9PS. UK, Anil Kumar Send response to journal: Re: Blood pressure lowering and stroke	Mant et al (1) state that the results of PROGRESS are not applicable to the stroke population in the community. One reason cited is that patients in the community were 12 years older compared to those recruited to PROGRESS. The authors explain the dangers of aggressive blood pressure lowering for the over-80s and recommend further urgent studies. There is still lack of guidance on blood pressure lowering in the over-80s (2); however, this is no reason to deprive this group of appropriate treatment. If, for example, a fit and active 81 year-old lady has a minor stroke then it seems appropriate to treat hypertension aggressively. It may be unethical for this lady to be recruited to a placebo arm of a blood pressure lowering trial, and be deprived of treatment that may prevent a stroke. It is thus simply not possible to perform randomised-controlled trials in all patient groups. Moreover, most studies actually ask more questions than they answer. For many cases, treatment is decided following discussion between patient and doctor, with the aid of the information provided by randomised-controlled trials. 1 Mant J, McManus R, Hare R. Applicability to primary care of national clinical guidelines on blood pressure lowering for people with stroke: cross sectional study. BMJ 2006; 332: 635-637. 2 Williams B, Poulter NR, Brown MJ, Davis M, et al. The BHS Guidelines Working Party Guidelines for Management of Hypertension: Report of the Fourth Working Party of the British Hypertension Society, 2004 - BHS IV. Journal of Human Hypertension 2004; 18: 139-185 Competing interests: None declared
More research or different research? 28 March 2006
Moyez Jiwa, Associate Professor General practice,University of Western Australia, WA 6010 Send response to journal: Re: More research or different research?	Mant et al are not the first to point out that patients in primary care are unlike those recruited to clinical trials.1 Neither was it surprising that almost two thirds of patients were not managed according to published guidelines. However it might be a mistake to assume that one is a consequence of the other. It is questionable whether the publication of yet more rigorously tested and evidence-based guidelines would be more enthusiastically implemented. General practitioners in South Yorkshire reviewed their clinical practice and published their findings.2 They suggest that even in the most committed practices the application of guidelines is a function of the patient’s knowledge, the amount of ‘noise’ in the consultation and the general practitioner’s determination to apply guidelines. In the last decade UK primary care has been offered incentives, target payments, to take a public health approach. Patients on the other hand steadfastly refuse to accept a reductionist view of their needs. There are many and complex reasons why a patient may not seek a prescription, referral or any other intervention and a different set of reasons why their general practitioner might not offer one. It is this research that might help to ‘target’ the ‘right’ patients arguably more than yet another epidemiological study. The latter is challenging, the former requires imaginative designs to explore in detail behaviour that is difficult to observe in practice and will be strongly influenced by the local context in which health care is delivered. References 1. Mant J, McManus RJ, Hare H. Applicability to primary care of national clinical guidelines on blood pressure lowering for people with stroke: cross sectional study. BMJ 2006;332: 635-7. 2. Jiwa M, Freeman J, Fisher C, Schrecker G, Gordon M, Reid J. Factors that impact on the application of guidelines in general practice: A review of medical records and structured investigation of clinical incidents in hypertension. Quality in primary care. 2005,13:215-22 Competing interests: None declared
National Stroke Guidance is applicable to primary care 7 April 2006
Wayne Sunman, Consultant Physician City Campus, Nottingham University Hospitals NHS Trust Send response to journal: Re: National Stroke Guidance is applicable to primary care	Editor, In their recent article(1), Mant et al conclude that the national clinical guideline on blood pressure lowering in stroke doesn’t apply to the UK general practice population. I cannot accept this. They conclude this because national guidance is largely based on the PROGRESS trial and patients in general practice with prior stroke were older, had a greater proportion of women and it had been longer since their stroke.. Whilst the median time elapsed since stroke is 8 months in the study and 30 months in general practice patients, patients were included in PROGRESS if they had a stroke between 2 weeks and 5 years beforehand(2). The authors of the PROGRESS study stated in their final paragraph that the benefits observed were independent of time since last stroke. The PATS study(3) was a double-blind RCT comparing the thiazide-like diuretic indapamide with placebo in 5665 Chinese patients who had been discharged previously with stroke. The median elapsed time since their last stroke was 14 months. Treatment caused a 29% reduction in stroke over the subsequent 3 years. Further reassurance that initiation of antihypertensives is beneficial beyond 8 months after a stroke. Finally, the PROGRESS results were subsequently analysed further and found to apply consistently by gender, age and geographical region(4). It is only safe to conclude that national guidance on the management of stroke should continue to apply to patients identified in general practice pending further research. The results of PROGRESS and PATS taken together support treatment of the patients within 5 years of a stroke with thiazide diuretic plus or minus an ACE inhibitor whatever their age or gender. If more certainty is required, then a pooled analysis of PATS, PROGRESS and also of the 1000 or so patients with prior stroke included in the HOPE trial(5) would be the logical next step. 1 Mant J, McManus RJ, Hare R. Applicability to primary care of national clinical guidelines on blood pressure lowering for people with stroke: cross sectional study. BMJ 2006; 332: 635-637. 2 PROGRESS collaborative group. Progress trial of perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358: 1033-1041. 3 PATS Collaborating Group. Post-stroke antihypertensive treatment study. A preliminary result. Chinese Med J 1995; 108: 710-717. 4 PROGRESS Collaborative Group. Perindopril-based blood pressure lowering in individuals with cerebrovascular disease: consistency of benefits by age, sex and region. J Hypertens 2004; 22: 653-9. 5 The Heart Outcomes Prevention Elaluation Study Investigators. Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000; 342: 145- 153. Competing interests: I have lectured for and have consulted for Servier and other pharmaceuticals marketing antihypertensive drugs.