Published online before print August 12, 2004, doi: 10.1161/01.STR.0000140887.52998.eb
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(Stroke. 2004;35:2238.)
© 2004 American Heart Association, Inc.
Letters to the Editor |
Re: Lawes et al: Blood Pressure and Stroke
Ochsner Clinic Foundation, New Orleans, La
Hopital Sud, Service de Néphrologie, Amiens, France
To the Editor:
We would like to commend Dr Lawes and collaborators1 on their thorough overview of antihypertensive therapy and stroke. However, we take issue with their conclusion that "initiating and maintaining BP reduction for stroke prevention is a more important issue than choice of initial agent." This may well be true for most antihypertensive drugs, but not for the ß-blockers.
There are no conclusive data showing that ß-blocker-based therapy reduces the risk of strokes or heart attacks in uncomplicated hypertension.2 To the contrary, in the double-blind prospective randomized Dutch TIA Trial, atenolol, despite lowering blood pressure, did not reduce strokes better than placebo.3 A similar lack of efficacy of atenolol was demonstrated in the double-blind Tenormin After Stroke and TIA study in hypertensive patients with established cerebrovascular disease.4 In the Medical Research Council study, neither heart attacks nor strokes were significantly reduced with atenolol when compared with placebo in contrast to the reduction seen with a thiazide diuretic.5 Thus, 3 independent randomized trials attest to the inefficacy of ß-blocker-based therapy in reducing cerebrovascular events. In both the Swedish Trial in Old Patients with Hypertension6 and the Coope study,7 which are often quoted to support efficacy of ß-blockers, more than two thirds of patients concomitantly received diuretics, and outcome results for the 2 drug classes were never analyzed separately.
Unfortunately, Dr Lawes et al1 also lump ß-blockers and diuretics into the same category. Because diuretics-based therapy is one of the most powerful ways to reduce the risk of strokes,8 this combination obfuscates the complete inefficacy of the ß-blockers.8 Not surprisingly, in the LIFE study an angiotensin receptor blocker was much more efficacious than a ß-blocker in reducing cerebrovascular events.9 Clearly, with regard to stroke reduction, not all antihypertensive drugs are created equal.10
References
1. Lawes CM, Bennett DA, Feigin VL, Rodgers A. Blood pressure and stroke: an overview of published reviews. Stroke. 2004; 35: 776–785.
2. Messerli FH, Beevers DG, Franklin SS, Pickering TG. ß-blockers in hypertension—the emperor has no clothes: an open letter to present and prospective drafters of new guidelines for the treatment of hypertension. Am J Hypertens. 2003; 16: 870–873.[CrossRef][Medline] [Order article via Infotrieve]
3. The Dutch TIA Trial Study Group. Trial of secondary prevention with atenolol after transient ischemic attack or nondisabling ischemic stroke. Stroke. 1993; 24: 543–548.
4. Eriksson S, Olofsson B-O, Wester P-O; for the TEST Study Group. Atenolol in secondary prevention after stroke. Cerebrovasc Dis. 1995; 5: 21–25.[CrossRef]
5. MRC Working Party. Medical Research Council trial of treatment of hypertension in older adults: principal results. BMJ. 1992; 304: 405–412.
6. Dahlof B, Lindholm LH, Hansson L, Scherstén B, Ekbom T, Wester P-O. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet. 1991; 338: 1281–1285.[CrossRef][Medline] [Order article via Infotrieve]
7. Coope J, Warrender TS. Randomised trial of treatment of hypertension in elderly patients in primary care. BMJ (Clin Res Ed). 1986; 293: 1145–1151.
8. Messerli FH, Grossman E, Lever AF. Do thiazide diuretics confer specific protection against strokes? Arch Intern Med. 2003; 163: 2557–2560.
9. Lindholm LH, Ibsen H, Dahlof B, Devereux RB, Beevers G, de Faire U, Fyhrquist F, Julius S, Kjeldsen SE, Kristiansson K, Lederballe-Pedersen O, Nieminen MS, Omvik P, Oparil S, Wedel H, Aurup P, Edelman J, Snapinn S; LIFE Study Group. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002; 359: 1004–1010.[CrossRef][Medline] [Order article via Infotrieve]
10. Fournier A, Messerli FH, Achard JM, Fernandez L. Cerebroprotection mediated by angiotensin II receptors—a hypothesis supported by recent randomized clinical trials. J Am Coll Cardiol. 2004; 43: 1343–1347.
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