Download Detection, Evaluation, and - CHEST Journal

Stroke Prevention in Atrial Fibrillation III randomised clini¬
cal trial. Lancet 1996; 348:633-38
9 Kutner M, Nixon G, Silverstone F. Physicians' attitudes
toward oral anticoagulants and antiplatelet agents for stroke
prevention in elderly patients with atrial fibrillation. Arch
Intern Med 1991; 151:1950-53
10 Bath PMW, Prasad A, Brown MM, et al. Survey of use of
anticoagulation in patients with atrial fibrillation. BMJ 1993;
307:1045
Lip GY, Tean KN, Dunn FG. Treatment of atrial fibrillation
in a district general hospital. Br Heart J 1994; 71:92-95
12 Laupacis A, Sullivan K, Canadian Atrial Fibrillation Antico¬
11
13
14
15
16
17
18
19
agulation Study Group. Canadian atrial fibrillation anticoag¬
ulation study: were the patients subsequently treated with
warfarin? Can Med Assoc J 1996; 154:1669-74
Stafford R, Singer DE. National patterns of warfarin use in
atrial fibrillation. Arch Intern Med. 1996; 156:2537-41
McCrory DC, Matchar DB, Samsa G, et al. Physician atti¬
tudes about anticoagulation for nonvalvular atrial fibrillation
in the elderly. Arch Intern Med 1995; 155:277-81
Schlicht JR, Davis RC, Naqi K, et al. Physician practices
regarding anticoagulation and cardioversion of atrial fibrilla¬
tion. Arch Intern Med 1996; 156:290-29
Atrial Fibrillation Investigators. Risk factors for stroke and
efficacy of antithrombotic therapy in atrial fibrillation: analy¬
sis of pooled data from five randomized controlled trials. Arch
Intern Med 1994; 154:1449-57
Gottlieb LK, Salem-Schatz S. Anticoagulation in atrial fibril¬
lation: does efficacy in clinical trials translate into effective¬
ness in practice? Arch Intern Med 1994; 154:1945-53
Andrews TC, Peterson DW, Doeppenschmidt D, et al.
Complications of warfarin therapy monitored by the Interna¬
tional Normalized Ratio versus the prothrombin time. Clin
Cardiol 1995; 18:80-82
Ansell JE, Hughes R. Evolving models of warfarin manage¬
ment: anticoagulation clinics, patient self-monitoring, and
patient self-management. Am Heart J 1996; 132:1095-100
20 Palareti G, Leali N, Coccheri S, et al. Bleeding complications
of oral anticoagulant treatment: an inception-cohort, prospec¬
tive collaborative
study (ISCOAT). Lancet 1996; 348:423-28
Dalen JE, Deykin D. Oral anticoagulants: mecha¬
nism of action, clinical effectiveness, and optimal therapeutic
range. Chest 1995; 108(suppl):231S-46S
22 European Atrial Fibrillation Study Group. Optimal oral anti¬
coagulant therapy in patients with nonrheumatic atrial fibril¬
lation and recent cerebral ischemia. N Engl J Med 1995;
333:5-10
23 Richton-Hewett S, Foster E, Apstein C. Medical and eco¬
nomic consequences of a blinded oral anticoagulant brand
change at a municipal hospital. Arch Intern Med 1988;
21 Hirsh
J,
148:806-08
24
Approved drug products.
17th ed.
Washington,
DC: US
Department of Health and Human Services, 1997.
25 Albers GW. Atrial fibrillation and stroke: three new studies,
three remaining questions. Arch Intern Med 1994; 154:
1443-48
26 Ezekowitz MD,
James KE. Stroke Prevention in Atrial Fi¬
brillation II Study [letter]. Lancet 1994; 343:1508-09
27 Stroke Prevention in Atrial Fibrillation Investigators. Bleed¬
ing during antithrombotic therapy in patients with atrial
fibrillation. Arch Intern Med 1996; 156:409-16
28 Connolly S. Stroke Prevention in Atrial Fibrillation II Study
[letter]. Lancet 1994; 343:1509
29 Fihn SD, Callahan CM, Martin DC, et al. The risk for and
severity of bleeding complications in elderly patients treated
with warfarin. Ann Intern Med 1996; 124:97-079
30 Rennie D. Thyroid storm [editorial]. JAMA 1997;
277:1238-43
31 Dong BJ, Hauck WW, Gambertoglio JG, et al. Bioequiva-
lence of generic and brand-name levothyroxine products in
the treatment of hypothyroidism. JAMA 1997; 277:1205-13
New Guidelines for
Prevention,
Detection, Evaluation, and
Treatment of Hypertension
Joint National Committee VI
HThe Joint National Committee (JNC) ofthe Na-*- tional High Blood Pressure Education Program
(NHBPEP) has published recurring documents to
in prevention, detection, and
guide the clinician
of
management hypertension. The 50th anniversary
of the founding of the National Heart, Lung, and
Blood Institute and the 25th anniversary of the
of the NHBPEP within that institute are
founding
marked
this year.
being
While there have been remarkable reductions in
morbidity and mortality attributable to hypertension
since 1972 (a 60% reduction in age-adjusted death
rates from stroke and 53% reduction in death rates
from coronary heart disease) coinciding with in¬
creased numbers of people controlling their hyper¬
tension, these dramatic improvements have slowed.
Recent reports from Minnesota have shown a de¬
crease in the awareness, treatment, and control of
hypertension compared to 10 years ago.12 Nation¬
ally, the prevalence of heart failure and the incidence
of end-stage renal disease, for both of which hyper¬
tension is a common antecedent, have increased
remarkably. Public health challenges also include
preventing the rise of blood pressure with age and
improving control rates from the current national
level of about 28%, with emphasis on controlling
isolated systolic hypertension. These observations
underscore the need to enhance professional educa¬
tion to translate the results of recent research into
improved public health. The sixth report of the JNC
the busy primary care clinician with suc¬
provides
cinct contemporary guidelines for prevention, detec¬
tion, evaluation, and treatment of hypertension.3
These guidelines contain tables and figures that
summarize the text. As in the past, members of the
American College of Chest Physicians will receive a
copy of these guidelines by mail. This report also will
be available on the World Wide Web (http://www.
and by calling (301)
nhlbi.nih.gov/nhlbi/nhlbi.htm)
251-1222. Cardiovascular risk assessment tools based
on data from epidemiologic studies can also be found
CHEST / 113 / 2 / FEBRUARY, 1998
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21759/ on 05/07/2017
263
the Web (www.amhrt.org/risk/catalog/risk_
assessment_guide_ca/page28.html).
On this occasion, the JNC utilized an evidencebased approach to the data as well as consensus. It
now includes the absolute, as well as relative, bene¬
fits resulting from treatment, because the absolute
benefit obtained by treating hypertension depends
on the absolute risk in the individual or population.
randomized clinical trials (RCTs) remain
Althoughsource
of evidence, they have shortcomings
the best
(eg, drop-ins, drop-outs; patients at high risk do not
participate in the trials; benefits of treatment accrue
over a time longer than the duration ofthe trial) and,
thus, treatment effects were extrapolated.
The accurate measurement of blood pressure is
described and information is provided about the value
of serial self-measurement (at home and at work) and
of ambulatory blood pressure monitoring. The normal
value for out-of-office daytime blood pressure is <135/
<85 mm Hg. Details are provided about obtaining the
necessary medical history, physical examination, and
limited number of routine tests (urinalysis; CBC; ECG;
potassium, sodium, creatinine, total
fasting glucose,
and
cholesterol,
high-density lipoprotein cholesterol
levels). Optional tests to be considered, particularly
when target organ disease or an identifiable cause of
hypertension is suspected, include creatinine clearance,
microalbuminuria, echocardiogram, ultrasound exami¬
nation of arteries, ankle/arm systolic pressure index,
and levels of low-density lipoprotein cholesterol, tri¬
hor¬
glycerides, calcium, uric acid, thyroid-stimulating
and
aldosterone.
mone, glycated hemoglobin, renin,
Very important recommendations include: a
new three-stage classification of blood pressure for
3 and 4 of the
which combines
on
adults,
stages
Table 1.Risk
Stage of Hypertension
classification first detailed in JNC V (1993); rec¬
ognizing the importance of high-normal blood
pressure in contributing to cardiovascular disease
and in progressing to stage 1 hypertension; and
increased emphasis on detecting overall cardiovas¬
cular risks and target organ diseases that can be
(Table 1). Clinicians should
easily established
into
one
place patients withofthethree riskof categories (A,
B, C) which, along
stage hypertension,
influences the decision about starting antihypertensive drug therapy (earlier or later than "usual")
(Table 1). A convenient notation encompasses an
individual's stage of hypertension and risk status,
eg, stage 1C would indicate an average blood
pressure of <160 mm Hg and/or <100 mm Hg in
a person with target organ damage and/or diabe¬
tes, prompting the need for aggressive manage¬
ment of the concomitant disorders and cardiovas¬
cular risks, as well as treating the blood pressure to
< 140/90 mm Hg. A detailed plan of
perhaps
action and goals should be developed with the
patient.
"The goal of prevention and management of hyper¬
tension is to reduce morbidity and mortalityby the least
intrusive means possible."3 Goal blood pressure is
and <90 mm Hg, with lower goals
recommended in certain comorbid conditions such as
diabetes, renal failure, and heart failure. Lifestyle
changes may prevent hypertension and may be defin¬
itive therapy in some individuals with high normal BP,
but are adjunctive therapy for all patients with hyper¬
tension. The lifestyle modifications recommended for
hypertension
prevention and management include:
reduction
(initial goal, 10 lbs), moderation in
weight
alcohol intake (<0.5-1.0 oz absolute alcohol), regular
<140
factors1
No TOD/CCD
Hg
Stratification and Treatment*
Risk Group A
No risk
mm
Risk
At least
No
Risk Group C
Group B
one
risk factor
TOD/CCD and/or diabetes, with
without other risk factors
or
diabetes, TOD/CCD
Lifestyle modification
Drug therapyVLM
High normal BP
Lifestyle modification*
(130-139/85-89 mm Hg)
Lifestyle modification
Lifestyle modification
Drug therapy/LM
Stage 1
(<6 mo)11
(140-159/90-99 mm Hg)
(<12 mo)
Drug therapy/LM
Drug therapy/LM
Drug therapy/LM
Stage 2
(160-179/100-109 mm Hg)
Drug therapy/LM
Drug therapy/LM
Drug therapy/LM
Stage 3 (>180/>110 mm Hg)
*TOD/CCD.target organ damage/clinical cardiovascular disease; includes heart diseases (left ventricular hypertrophy, angina, prior myocardial
infarction, prior revascularization, heart failure), stroke or transient ischemic attack, nephropathy, PAD, retinopathy; PAD=peripheral arterial
disease; LM=lifestyle modification.
'Major risk factors include smoking, dyslipidemia, diabetes mellitus, age >60 yr, men and postmenopausal women, family history of cardiovascular
disease (women <65 yr, men <55 yr).
*For patients with heart failure or renal
insufficiency, or those with diabetes.
"For patients with multiple risk factors, consider drugs as initial therapy.
Adapted from reference 3.
264
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21759/ on 05/07/2017
Editorials
physical activity (30- to 45-min brisk walk most days),
moderation in sodium intake (100 mmol/day), and
increase in potassium intake (90 mmol/day). Tobacco
avoidance and aggressive treatment of diabetes mellitus
and lipid disorders are most important for overall
cardiovascular risk reduction.
Drug therapy is discussed in detail: once-a-day
drugs are advised, combinations are useful, and
special consideration is given to many comorbid
conditions and drugs that affect therapeutic deci¬
sions. Managed care programs have an important
role in coordinating approaches to care, using various
health-care professionals and appropriate frequency
of visits, patient counseling, and controlled formu¬
laries while monitoring outcomes (eg, blood pressure
levels, adherence to therapy, morbidity and mortal¬
ity, resource utilization). Hypertension experts can
provide guidance and counseling, particularly for
patients with secondary hypertension, resistance to
treatment, and complex comorbid conditions.
When the decision has been made to start drug
therapy for uncomplicated primary hypertension, in
the absence of contraindications, diuretics and
P-blockers should be chosen because numerous
RCTs have shown a reduction in morbidity and
mortality with these agents. There are additional,
compelling indications for these and other antihypertensive drugs in certain conditions based on RCTs
results. In patients with diabetes type I with proteinuria, angiotensin-converting enzyme (ACE) I agents
are indicated; in heart failure, ACE I and diuretics;
myocardial infarction, P-blockers (nonintrinsic
sympathomimetic activity) and ACE I (with systolic
dysfunction). For the treatment of hypertension in
older persons, diuretics are preferred, and in those
with isolated systolic hypertension, a long-acting
dihydropyridine calcium antagonist can also be con¬
in
sidered. In other clinical situations where there are
not yet sufficient outcomes data, the choice of
therapy should be individualized based on the pa¬
tient's needs. Specific therapies for persons with left
ventricular hypertrophy, coronary artery disease,
heart failure, pulmonary disorders, pregnancy, and
renal insufficiency are described. The choices of
drugs in the management of hypertensive emergen¬
cies and urgencies include the newer intravenous
vasodilators, nicardipine and fenoldopam.
guidelines must be adapted and
and individual situations.
implemented
Widespread application of the recommendations
contained in the report should improve detection,
treatment, control, and prevention of hypertension.
Further reductions in stroke and coronary disease
can be anticipated, and attenuation in end-stage
These national
in local
renal disease and heart failure is expected as the
NHBPEP looks toward the next 25 years.
Sheldon G. Sheps, MD, FCCP
Rochester, Minnesota
Richard A. Dart, MD, FCCP
Marshfield, Wisconsin
Dr. Sheps is Emeritus Professor of Medicine, Mayo Clinic; Dr.
Dart is a member of the Department of Hypertension/Nephrology, Marshfield Clinic, and Chair of the ACCP Section on
Hypertension and Clinical Cardiology.
1
2
REFERENCES
Meissner I, Whisnant JP, Sheps SG, et al. Stroke prevention:
assessment of risk in a community. The SPARC Study, part 1:
blood pressure trends, treatment and control [abstract]. Ann
Neurol 1997; 42:433
Luepker RV, McGovern PG, Sprafka JM, et al. Unfavor¬
able trends in the detection and treatment of hypertension:
the Minnesota Heart Survey [abstract]. Circulation 1995;
91:938
3 The Sixth
Report of the Joint National Committee on Pre¬
vention, Evaluation and Treatment of High Blood Pressure.
Arch Intern Med 1997; 157:2413-46
Ventilatory Impairment in
Asthma
Perceptions vs Measurements
"T\ ecisions concerning asthma management rely
**J on assessment of respiratory problem
severity,
its known or projected course, and on the response
of individual patients to their disease and treatment.
The merits and the limitations of various methods for
grading asthma, also called ROAD (reversible ob¬
structive airways disease) or VOID (variable obstruc¬
tive intrabronchial disease), have been reviewed
but the conclusion that "attempts to
extensively,1-5
a
multifactorial.
index have been
develop
unsuccessful"2?734 encourages additional efforts in
this direction. In this issue of CHEST (see page 272),
Teeter and Bleecker report that certain pulmonary
function tests, the peak expiratory flow rate (PEF or
PEFR), and the FEV^ are more reliable than sub¬
jective perceptions for guiding the treatment of
.
.
.
.
They also state that a 17% incidence of a
asymptomatic airway obstruction" (if "ob¬
"relatively
struction" means simply a PEF below established
norms) is of questionable significance and that "the
long-term outcome of untreated or undertreated
asthmatics (italics mine) is not known." The need to
examine bronchodilator-induced reversibility for
those with "asymptomatic obstruction" is not consid¬
ered sufficiently in this report.
asthma.
CHEST / 113 / 2 / FEBRUARY, 1998
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21759/ on 05/07/2017
265