The PROGRESS trial three years later: time for a balanced report of effectiveness

doi:10.1136/bmj.329.7472.968

From trainee to consultant, BMJ Group offers doctors around the world tailored information, special events, learning resources and recruitment services at every step along their career path.

... by doctors, for doctors, for patients
We are open for entries!

Online learning

BMJ Learning

High-quality CME / CPD for doctors and other healthcare professionals. BMJ Learning features hundreds of accredited, peer-reviewed learning modules in text, video, and audio formats. Find out more

Courses and Qualifications

BMJ Masterclasses

BMJ Masterclasses, led by experts, help clinicians to use the latest evidence and recent guidelines in practice and meet their CPD/CME requirements. Find out more

Exam Preparation

The leading provider of online exam preparation, helping over 167,000 healthcare professionals to pass their exams. Find out more

onExamination

Search all BMJ education articles:

From

Limit by

Access to the full text of this article requires a subscription or payment. Please log in or subscribe below.

Richard Wennberg (Richard.Wennberg@uhn.on.ca), associate professor1,
Camilla Zimmermann, lecturer1

¹ Department of Medicine, University of Toronto, University Health Network, Toronto, ON, Canada M5T 2S8

Correspondence to: R Wennberg

Has the use of the phrase “perindopril based blood pressure lowering regimen” resulted in an oversimplistic and hence inaccurate interpretation of the results of the PROGRESS trial creeping into the literature and clinical practice?

Introduction

Any doctor who keeps up to date with the stroke literature will be familiar with PROGRESS—the perindopril protection against recurrent stroke study,1 a clinical trial which had resulted, by February 2004, in more than 35 ancillary publications. The aim of the study was to “resolve clinical uncertainty about the efficacy and safety of routine blood-pressure-lowering therapy for individuals with a history of stroke or transient ischemic attack.”1 The trial found that blood pressure lowering was safe and effective, but three years after its publication, the optimal antihypertensive regimen for secondary stroke prevention remains unclear. The title of the study, together with its results as reported, may lead the unwary reader to conclude that perindopril used alone protects against recurrence of stroke. Although this was actually not a finding of PROGRESS, the study design and data presentation obfuscate this fact rather than making it clear.

Design of the trial

The PROGRESS trial had a “flexible” design, which meant that not all patients received the same antihypertensive regimen. Patients who had had a stroke or transient ischaemic attack in the previous five years were eligible. They were also required to have “no definite indication (such as heart failure) for treatment with an ACE inhibitor and no definite contraindication (such as previous intolerance) to such treatment.” The entry criteria did not include blood pressure, but treatment with agents other than angiotensin converting enzyme inhibitors was recommended to patients with uncontrolled hypertension before they entered the trial. Patients were then randomised, on a double …