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| Relevance of PROGRESS findings to primary care questioned |
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24 February 2006
Important differences in stroke patient characteristics have been detected between those in primary care and the study population of the perindopril protection against recurrent stroke study (PROGRESS).
National guidelines for target blood pressure in patients with a history of stroke are "heavily influenced" by the findings of PROGRESS, say the researchers from the University of Birmingham in the UK. However, they note that "a question that has been neglected is whether these guidelines are relevant to primary care, which is where more treatment of blood pressure occurs."
To address this issue, the team compared the characteristics of the 6105 patients included in PROGRESS with those of 520 stroke patients identified from the records of seven general practices in South Birmingham. The average age of the Birmingham patients was 76 years and the median time since their last stroke was 2.5 years. In contrast, PROGRESS patients were 64 years old, on average, and had suffered a cerebrovascular event a median of 8 months previously.
The investigators raise the point that the reduction in the risk of stroke may be offset by increased mortality in older patients. "The longer time lapse since the most recent cerebrovascular event in patients in primary care is also important," they comment, "as risk of recurrence declines over time, and the harm-to-benefit ratio from aggressive treatment becomes less favourable."
Hypertension was present in 38% of primary care patients and 48% of those in PROGRESS; however, 68% of patients in primary care were receiving antihypertensive medication, compared with just half of the PROGRESS population. Women were underrepresented in the PROGRESS trial, at just 30%, compared with 54% in primary care.
Dr Jonathan Mant and colleagues recognise that patients in clinical trials are often different from those seen in medical practice. "In many cases this does not matter," they say, "but in the case of blood pressure lowering after stroke it does, as the differences are so great as to undermine the applicability of the research to primary care."
Reference:
Br Med J 2006; online publication.
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