Impact of ASCOT on hypertension treatment and guidelines in older adults

15. Millard P. A case for the development of departments of gero-comy in all district hospitals: a discussion paper. Hypertension remains the most prevalent and preventable cause of cardiovascular (CHD) and cerebrovascular (CVD) disease, and there is good evidence that antihypertensive drugs are effective [1]. Interest in the condition remains high, with a number of recent large studies and published guidelines by both the BHS (British Hypertension Society) and the National Institute of Clinical Excellence (NICE) [2, 3]. The main questions at present are: 1. Does it matter which drug is used? 2. Are the benefits of antihypertensive agents purely related to their blood pressure (BP)-lowering effects or do some agents have additional beneficial effects whilst others have adverse metabolic effects? 3. Are newer agents more effective than the widely used thiazides and β-blockers in prevention of CHD and CVD? More than 2 million people in the UK are still prescribed β-blockers (mainly for hypertension) [4]. The recently published ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm ASCOT-BPLA) [5] trial provides important data that partly answer these questions and are likely to change clinical practice further. We have restricted discussion to the BP-lowering arm of the study although there was also a lipid-lowering arm [6], which showed significant benefits with atorvastatin over placebo in CHD and CVD outcomes. The ASCOT trial [5] is a large British and Scandinavian randomised control trial (RCT) involving >19,000 patients and comparing two different drug regimes—either a calcium channel blocker (amlodipine) adding in an angiotensin-converting enzyme inhibitor (ACE-I) (perindopril) as needed, or a β-blocker (atenolol) adding in a thiazide diu-retic (bendroflumethiazide) as needed. Patients were moderate risk untreated (>160/100 mmHg) or treated hypertensives who had failed to reach target (>140/90 mmHg), and who had at least three of a number of cardio-vascular risk factors (including left ventricular hypertrophy, type 2 diabetes, peripheral vascular disease, microalbuminu-ria, prior stroke or transient ischaemic attack and a number of other factors). The majority were white (95%) and male (77%), mean age was 63 years (range 40–79), and 81% were already on at least one antihypertensive agent. Patients were followed-up regularly for >5 years and drugs titrated on an open design aiming for target <140/90 mmHg or <130/80 mmHg for diabetics. The results showed a mean difference in BP-lowering effect (2.7/1.9 mmHg) between the groups in favour of the calcium channel blocker±ACE-I group that is both statistically and clinically meaningful. …