Eficacia de los fármacos antihipertensivos en monoterapia y combinación

Paz Bermejo, Marco
Background. The relative efficacy of antihypertensive drugs/combinations is not well known; Identifying the most effective ones, and the patients’ characteristics associated to best performance of the drugs will improve the management of these patients. Objectives. To assess the blood pressure reduction attributed to antihypertensive drugs, both as monotherapy and in combination, and identify characteristics associated to blood pressure decrease. Determining these data, develop practical tables that facilitate the choice of antihypertensive drug, based on the basal blood pressure (BP) and those of the objective to be achieved. Data sources. Pubmed, Cochrane Central Register of Controlled Trials from inception through July 2012 and selected papers. Study eligibility criteria. Double blind randomized clinical trials with study population ≥50 or ≥25 if the study was a crossover, follow-up of at least 8 weeks, and available required data. Study appraisal and synthesis methods. Study data were independently extracted by multiple observers and introduced in an electronic database. Inconsistencies were resolved by discussion and referral back to the original articles. Meta-analysis was performed using a Bayesian framework. Main Outcome(s) and Measure(s): Mean decrease in systolic (SBP) and diastolic blood pressure (DBP) achieved by each drug or combination. Later, a second analysis was performed based on the results of the ATOM study. To convert the mean doses of the different drugs and combinations in commercialized doses, the conclusions of the study by Law et al have been applied. Results. 208 trials including 94,305 patients were identified. In monotherapy, most drugs achieved 10–15 mmHg SBP and 8-10 mmHg DBP decreases. Olmesartan/amlodipine, olmesartan/hydrochlorothiazide, felodipine/metoprolol and valsartan/hydrochloro-thiazide were the combinations leading to the greatest mean SBP reductions (> 20 mmHg). Female gender and Body mass index (BMI) >25Kg/m2 were associated to more pronounced SBP and DBP reductions, while Afro-American ethnicity was associated to blood pressure reductions smaller than the median. Results were adjusted by study duration, cardiovascular disease and diabetes mellitus. Based on the results, two tables were drawn, one for systolic BP and the other for diastolic BP, where the doses of the different drugs and combinations are classified according to the BP decrease that can be expected from them. In order to favor the use of the tables in clinical practice, the different drugs have been grouped in intervals of 10 millimeters of mercury (mmHg) for the decrease of the systolic BP and of 5 mmHg for the diastolic BP. Limitations. Data corresponded to those obtained in every one of the included trial and, therefore, we did not have access to the individual data of each patient; the analysis of the combinations was limited to the most recent ones. Conclusions and implications. Certain drug combinations achieve blood pressure reductions between 20-25/10-15mmHg. Gender, ethnicity and obesity are associated to antihypertensive response. This information can contribute to better selection of the antihypertensive drug, depending on the magnitude of pre-treatment blood pressure elevation. Guidelines should be revised ​
​ADVERTIMENT. Tots els drets reservats. L'accés als continguts d'aquesta tesi doctoral i la seva utilització ha de respectar els drets de la persona autora. Pot ser utilitzada per a consulta o estudi personal, així com en activitats o materials d'investigació i docència en els termes establerts a l'art. 32 del Text Refós de la Llei de Propietat Intel·lectual (RDL 1/1996). Per altres utilitzacions es requereix l'autorització prèvia i expressa de la persona autora. En qualsevol cas, en la utilització dels seus continguts caldrà indicar de forma clara el nom i cognoms de la persona autora i el títol de la tesi doctoral. No s'autoritza la seva reproducció o altres formes d'explotació efectuades amb finalitats de lucre ni la seva comunicació pública des d'un lloc aliè al servei TDX. Tampoc s'autoritza la presentació del seu contingut en una finestra o marc aliè a TDX (framing). Aquesta reserva de drets afecta tant als continguts de la tesi com als seus resums i índexs.