Hyperlipidemias: McAlister FA

McAlister FA, Levine M, Zarnke KB, Campbell N, Lewanczuk R, Leenen F, Rabkin S, Wright JM, Stone J, Feldman RD, Lebel M, Honos G, Fodor G, Burgess E, Tobe S, Hamet P, Herman R, Irvine J, Culleton B, Petrella R, Touyz R, Anonymous00140. · Division of General Internal Medicine, University of Alberta, Edmonton, Canada. · Can J Cardiol. · Pubmed #11381277 links to  free full text

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the therapy of hypertension in adults. OPTIONS: For patients with hypertension, there are a number of lifestyle manoeuvres and antihypertensive agents that may control blood pressure. Randomized trials evaluating first- line therapy with thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers, centrally acting agents or angiotensin II receptor antagonists were reviewed. OUTCOMES: The health outcomes considered were changes in blood pressure, cardiovascular morbidity, and cardiovascular and/or all-cause mortality rates. Economic outcomes were not considered due to insufficient evidence. EVIDENCE: Medline searches were conducted from the period of the last revision of the Canadian Recommendations for the Management of Hypertension (May 1998 to October 2000). Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other studies. All relevant articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts. VALUES: A high value was placed on the avoidance of cardiovascular morbidity and mortality. BENEFITS, HARMS, AND COSTS: Various lifestyle manoeuvres and antihypertensive agents reduce the blood pressure of patients with sustained hypertension. In certain settings, and for specific classes of drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality. RECOMMENDATIONS: The present document contains detailed recommendations pertaining to all aspects of the therapy of patients with hypertension, including lifestyle modifications proven to lower blood pressure, treatment thresholds, target blood pressures, choice of agents in various settings and strategies to enhance adherence. Lower thresholds for blood pressure treatment are advocated for people with other cardiovascular risk factors or established hypertensive target organ damage. Implicit in the recommendations for therapy is the principle that treatment should be individualized for each patient and the choice of agent should be dictated by coexistent conditions. For the treatment of uncomplicated essential hypertension, thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors or calcium channel blockers may be appropriate, depending on individual circumstances. VALIDATION: All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Only those recommendations achieving high levels of consensus are reported here. These guidelines will be updated annually.

Straus SE, Majumdar SR, McAlister FA. · Division of General Internal Medicine, Department of Medicine, University Health Network, Toronto General Hospital, 200 Elizabeth St, ENG 248, Toronto, Ontario, Canada M5G 2C4. · JAMA. · Pubmed #12234233 links to  free full text

Abstract: CONTEXT: Stroke is a major cause of morbidity and mortality, and the application of evidence for stroke prevention varies considerably. OBJECTIVE: To review the most recent, high-quality evidence for primary and secondary stroke prevention. DATA SOURCES AND STUDY SELECTION: Searches of MEDLINE, The Cochrane Library, and the ACP Journal Club were performed to identify English-language articles published from 1998 to 2001 that focused on primary and secondary stroke prevention. The references of each retrieved article were scanned, and experts in the field were contacted to identify additional relevant articles. DATA EXTRACTION: Each of the articles was appraised, and its quality was graded with levels of evidence based on specific scientific methods that affect a study's validity. DATA SYNTHESIS: For primary prevention of stroke, adequate blood pressure reduction, and treatment of hyperlipidemia, use of antithrombotic therapy in patients with atrial fibrillation and of antiplatelet therapy in patients with myocardial infarction are effective and supported by evidence from several randomized trials. Effective strategies for the secondary prevention of stroke include treatment of hypertension and hyperlipidemia, antithrombotic therapy for patients with atrial fibrillation, antiplatelet therapy, and carotid endarterectomy in patients with severe carotid artery stenosis. CONCLUSIONS: Stroke is a major public health concern, and a significant body of evidence supports many primary and secondary prevention strategies.

Straus SE, Majumdar SR, McAlister FA. · Division of General Internal Medicine, Department of Medicine, University Health Network, Toronto General Hospital, 200 Elizabeth St, ENG 248, Toronto, Ontario, Canada M5G 2C4. · JAMA. · Pubmed #12234234 links to  free full text

Abstract: Stroke is a leading cause of morbidity and mortality in most developed nations. There is a significant body of evidence supporting strategies that target primary and secondary stroke prevention. This evidence cannot be broadly applied to all patients, and each patient's situation and values must be considered with regard to shared evidence-based decision making. Several models can be used to apply evidence to individual patients, including formal clinical decision analysis, decision aids, or simpler tools such as the likelihood of being helped vs harmed. Various programmatic models of providing patient care in stroke prevention may also be useful; these include specialized clinics or disease-management programs, anticoagulation management services, and self-testing and management of anticoagulation by patients.