By Neil R. Poulter
Here are speedy solutions to universal scientific questions with regards to cardiovascular threat. Taking a guidelines-driven technique, the writer has simplified the large variety of medical offerings on hand to the doctor assessing their sufferer for cardiovascular risk.
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With this in mind, the JNC 7 and the latest European guidelines formally recommend combination therapy as first-line treatment (see Fig. 11). Despite the need to use two drugs or more for BP control in most patients, the ASCOT trial is the only trial reporting before 2008 which was specifically designed to compare the effects of two totally different combinations of antihypertensive treatment (see Fig. 12). This trial showed that the use of an antihypertensive regimen based on the CCB amlodipine, and adding the ACE inhibitor perindopril as required to reach BP targets (<140/90 mmHg for non-diabetics and <130/80 for diabetics), was superior to a regimen based on the β-blocker atenolol and adding the thiazide bendroflumethiazide as required, in terms of all major 40 • STRATEGIES FOR CARDIOVASCULAR RISK MANAGEMENT Fig.
However, only one of these—the MIRACL (Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering) trial—is a placebo-controlled trial to assess the short-term impact of immediate treatment. The evidence from these three trials supports the view that early in-hospital statin treatment is of benefit in reducing the risk of further CV events in the short term. Therefore, the current recommendation is that all people with acute atherosclerotic (coronary, cerebral, and peripheral) disease, but not cerebral hemorrhage, should be prescribed a statin in hospital regardless of the initial cholesterol value.
It emphasizes to the person with the disease the importance of lipid lowering, by both lifestyle and drug intervention, for their future CV health. • Starting treatment in hospital is more likely to result in the same treatment being continued in general practice. There will be clinical exceptions to this policy—for example, a person with stroke-related dementia and acute atherosclerotic disease may not be suitable for statin treatment. Assessment for secondary causes of dyslipidemia should take place at the same time.