[AF] tratamiento de la hipertensión y otros absurdos farmacoterapeuticos

Pedro del Río Pérez pedrodelrio en ono.com
Vie Mar 11 22:23:41 CET 2011

Sobre Primarycare al menos José Ramón y yo en alguna ocasión 
hemos comentado algo. 
Por si os interesa su dirección para darse de alta es: 
El contenido de su último envío es el siguiente y que incluye el 
trabajo que comenta Emilio Pol:

Interesting new titles

The following titles have been registered with the Cochrane Collaboration.
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* Antibiotics for acute diverticulitis
* Locally applied haemostatic agents in the management of acute
* Apomorphine for the treatment of erectile dysfunction
* Crisis interventions for borderline personality disorder

practical evidence about real life situations  

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produce the P.E.A.R.L.S. (click here
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Access http://www.cochraneprimarycare.org/  to view the PEARLS online. 

The actual Cochrane abstracts for the P.E.A.R.L.S are at

210. Topical glyceryl trinitrate may be effective in rotator cuff disease

211. Thiazides best first choice for hypertension

212. Insufficient evidence for statins in age-related macular degeneration

213. Insufficient evidence for interventions for post-stroke fatigue


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Bruce Arroll 1,  Jaap van Binsbergen 2, Tom Fahey 3, Tim Kenealy  1,  
Floris van de Laar 2

Tilly Pouwels 2
Secretary to Cochrane Primary Health Care Field
email: t.pouwels en cochraneprimarycare.org 

The Cochrane Primary Health Care Field is a collaboration between:
1  New Zealand Branch of the Australasian Cochrane Centre at the
Department of General Practice and Primary Health Care, University of
Auckland and funded by the New Zealand Guidelines Group;

2  Academic Department of Primary and Community Care in The
Netherlands, The Dutch College of General Practitioners, and the
Netherlands Institute for Health Services Research;

3  Department of General Practice, Royal College of Surgeons in
Ireland, Dublin.  


Topical glyceryl trinitrate may be effective in rotator cuff disease

Clinical question How effective is topical glyceryl trinitrate (GTN)
for rotator cuff disease? 
Bottom line Three small studies, 1 at moderate risk of bias and 2 at
high risk of bias, assessed the effectiveness of GTN but each reported
different treatment regimens and different outcome measures. They also
included participants with differing duration of symptoms. There is some
evidence from 1 study at high risk of bias that topical GTN is more
effective than placebo for rotator cuff disease among patients with acute
symptoms (less than 7 days' duration), but there is insufficient evidence to
be certain about longer term effects. Headache was a common side effect in 1
trial and any benefits of treatment need to be balanced against the risk of
Caveat The inclusion criteria varied between studies and the selective
reporting of outcomes limited the analysis of the available data. The
effects on pain of GTN patches (1.25mg/day), along with rehabilitation
instruction (such as exercise) and of GTN patches (5mg/day) compared to
injection with corticosteroid and painkillers, were not reported by the
studies included in the review. It is uncertain whether GTN patches
(5mg/day) eliminate symptoms of rotator cuff disease because of the very low
quality of the evidence. Improvement in people's physical function was not
measured by any of the studies included in the review. 
Context Topical GTN has been used to treat chest pain for many years, and
has been proposed as a promising treatment for muscle and tendon injuries.
For treatment of soft tissue conditions, GTN is delivered topically, through
the skin, using medicated patches.  
Cochrane Systematic Review Cumpston M et al. Topical glyceryl
trinitrate for rotator cuff disease. Cochrane Reviews 2009, Issue 3. Article
No. CD006355. DOI: 10.1002/14651858.CD006355.pub2. This review contains 3
studies involving 121 participants. 
PEARLS No. 210, November 2009, written by Brian R McAvoy 

Thiazides best first choice for hypertension

Clinical question What are the most effective first-line
antihypertensive drugs? 
Bottom line First-line low-dose thiazides (eg, hydrochlorothiazide
<50mg) are more effective than first-line high-dose thiazides (eg,
hydrochlorothiazide 50mg or more) and first-line beta-blockers, in reducing
mortality and morbidity (stroke, myocardial infarction and heart failure).
For total cardiovascular events over 5 years, the NNT* is 20 in moderate to
severe hypertension (>160/100mmHg) and the NNT is 120 in mild hypertension
(140-160/90-100mmHg). Evidence for first-line ACE inhibitors is similar to
low-dose thiazides but less robust, and ACE inhibitors are more expensive
than thiazides. Evidence for first-line calcium channel blockers is
insufficient. *NNT = number needed to treat to benefit 1 individual. 
Caveat Over 72% of participants in this review represent a primary
prevention population.There are no randomised controlled trials comparing
first-line use of other classes of drugs, such as angiotensin receptor
blockers or alpha blockers. 
Context One of the major decisions involved in the management of patients
with elevated blood pressure is which drug to choose first. The decision
should be informed by the best available evidence of reduction of the
outcomes that are important to the patient, ie, the ability of the drug to
reduce the adverse health outcomes associated with elevated blood pressure
(stroke, myocardial infarction and mortality). 
Cochrane Systematic Review Wright JM and Musini VM. First-line drugs
for hypertension. Cochrane Reviews 2009, Issue 3. Article No. CD001841. DOI:
10.1002/14651858.CD001841.pub2. This review contains 57 studies involving
58,040 participants. 
PEARLS No 211, October 2009, written by Brian R McAvoy 

Insufficient evidence for statins in age-related macular degeneration

Clinical question How effective are statins in delaying the onset
and/or progression of age-related macular degeneration (AMD)? 
Bottom line In the one completed trial, the analyses of 30 participants
showed no statistically significant difference between the simvastatin and
the placebo arm in visual acuity at 3 months of treatment or 45 days after
the completion of treatment. The lens and retina status were unchanged
during and after the treatment period for both groups. In the ongoing trial,
the preliminary analyses of 42 participants who completed 12 months'
follow-up did not show a statistically significant difference between the
simvastatin and the placebo arm in visual acuity, drusen score or visual
function (effect estimates and confidence intervals were not available).

Caveat There were only 2 small studies, one of which is still ongoing. 
Context AMD is a progressive late onset disorder of the macula that affects
central vision. Although AMD is the leading cause of blindness in people
over 65 years in industrialised countries,1 its pathogenesis is not clearly
understood. Recent epidemiologic, genetic and pathological evidence has
shown AMD shares a number of risk factors with atherosclerosis, leading to
the hypothesis that statins may exert protective effects in AMD. 
Cochrane Systematic Review Gehlbach P et al. Statins for age-related
macular degeneration. Cochrane Reviews 2009, Issue 3. Article No. CD006927.
DOI: 10.1002/14651858.CD006927.pub2. This review contains 2 studies
involving 72 participants. 
PEARLS No. 212, November 2009, written by Brian R McAvoy 
1. Congdon NG et al. JAMA 2003;290:2057-60
Insufficient evidence for interventions for post-stroke fatigue

Clinical question How effective are interventions for post-stroke
Bottom line This review found 3 small, randomised controlled trials that
recruited people with a stroke to 3 treatments - 2 different drug treatments
(fluoxetine and tirilazad) and one chronic disease self-management
programme. At follow-up, there was no difference in fatigue levels between
the patients who received the active treatments and those who received usual
care or placebo. However, the trials were too small to provide firm
conclusions and further trials are required. Currently, there is
insufficient evidence to guide practice in treating fatigue following
Caveat There were only 3 completed studies, providing data on a total of
226 patients, and these involved 3 different interventions. There were
methodological limitations with all 3 trials. It was not possible to perform
meta-analysis as the interventions were too dissimilar. 
Context Estimates of the prevalence of fatigue after stroke range from 16%1
to 70%,2,3 depending on the population studied (eg, inpatients or community
patients, time since stroke, severity of stroke), whether people with
depression were included or excluded, and how fatigue was identified (eg,
single question or fatigue scales). 
Cochrane Systematic Review McGeough E et al. Interventions for
post-stroke fatigue. Cochrane Reviews 2009, Issue 3. Article No. CD007030.
DOI: 10.1002/14651858.CD007030.pub2. This review contains 3 studies
involving 226 participants. 
PEARLS No. 213, November 2009, written by Brian R McAvoy 
1. Glader E-L et al. Stroke 2002;33:1327-33.
2. Carllson GE et al. Cerebrovasc Dis 2003;16:383-88.
3. Leegard OF. Acta Neurol Scand 1983;67:348-55.
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