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Gold, incentives and meh

Second MIs plummet but GP prevention remains uneven

GPs' treatment of hypertension is set to be revolutionised with this week's publication of the landmark ASCOT trial.

The formal release of the data on The Lancet website has sparked intense debate over the future of ?-blockers and diuretics in hypertension.

In an unprecedented move, NICE announced it would revise its guidance in light of the data and release new advice within six months.

ASCOT found an ACE inhibitor and calcium channel blocker reduced cardiovascular mortality by 24 per cent relative to a ?-blocker and diuretic (see right).

Practices are braced for an influx of patients wanting the newer drug combination.

The trial investigators urg-ed GPs to use the ACE inhibitor/calcium channel blocker combination as standard first-line therapy.

Joint study leader Professor Peter Sever, professor of clinical pharmacology at Imperial College London, said: 'The ABCD guidelines will probably be changed to ACD. You should follow that by asking why would you choose a diuretic first-line. I personally would choose a calcium channel blocker.'

Fellow researcher Professor Neil Poulter, president of the British Hypertension Society, said: 'It would be hard now to offer a ?-blocker plus diuretic. The BHS is meeting the week after next and we're going to look at whether we change our guidance. My belief is that the B might drop out of first-line therapy.'

The BHS and NICE have set up a joint expert working group to examine the data's implications ­ but some PCTs are already issuing local guidance removing ?-blockers from first-line treatment.

CHD leads approached by Pulse were split on the implications of the new data, with some saying they would change practice immediately, but others planning to wait for the guidance review (see right).

Cardiovascular experts warned against a knee-jerk reaction to the results.

Dr Barry Davis, a lead investigator for the ALLHAT trial, which backed use of diuretics first-line, said ASCOT was a 'very important' study that suggested ?-blockers should not be used first-line ­ but provided no evidence to question use of diuretics.

Dr Terry McCormack, deputy-chair of the Primary Care Cardiovascular Society, questioned whether the results were applicable to all ?-blockers or just atenolol.

Professor Bryan Williams, chair of the NICE/BHS expert working group, cautioned GPs to wait for new guidance before changing practice.

The Anglo-Scandinavian Cardiac Outcomes Trial

Amlodipine/ perindopril compared with atenolol/ bendroflumethiazide in 19,257 hypertensive patients with at least three additional CVD risk factors.

Patients in the amlodipine/ perindopril arm had:

·16 per cent fewer cardiovascular events and procedures

·24 per cent lower cardiovascular mortality

·23 per cent fewer fatal and non-fatal strokes

·30 per cent less new onset diabetes

·A non-significant 10 per cent fewer non-fatal MIs and coronary heart disease deaths

Source: Lancet, Sept 4 early online publication

What I will do now

We'll try prescribing ACE inhibitors and calcium channel blockers in new patients, although we will not be changing policy for existing patients until we have guidance from NICE. Dr Pravin Shah, CHD lead for South Stoke PCT

It should change our practice. In patients on a ?-blocker and diuretic it seems reasonable to reconsider whenever the opportunity arises. Dr George Kassianos, CHD lead for Bracknell Forest PCT

The degree of BP-lowering is more important than the agent used. Until the benefits claimed in ASCOT are consolidated in guidance there's no reason to change practice. Dr Rubin Minhas, CHD lead for Medway PCT

The main thing is to be more reserved in use of ?-blockers. There's lots of good evidence on thiazides, which are a very cost-effective first-line medication. Dr Chris Harris, CHD lead for South West Bradford PCT

There will be repercussions on our practice but we'll wait for the expert panel to sift through the data. Dr Gerald Partridge, CHD lead for Airedale and Bradford North PCTs

By Emma Wilkinson

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