Saturday, January 18, 2014

Hypertension or Evidence Vs. Experts fight ! Why Beta-blockers , and some Diuretics left unpopular in JNC8

“There has been a carefully guarded secret in medicine: Evidence is often
inconclusive, and experts commonly disagree about what it means.

The new guidelines says that people 60 years and older can seek a systolic blood pressure goal (the top number) of 150 or less. The old guidelines says that 140 or less should be the goal.
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Before receiving alpha-blockers, beta-blockers, or any of several miscellaneous agents, under the JNC 8 guidelines, patients would receive a dosage adjustment and combinations of the 4 first-line therapies. Triple therapy with an ACEI/ARB, CCB, and thiazide-type diuretic would precede use of alpha-blockers, beta-blockers, or any of several other agents.   These new guidelines all but eliminate use of beta-blockers (including nebivolol), alpha-blockers, loop diuretics, alpha1/beta-blockers, central alpha2-adrenergic agonists, direct vasodilators, aldosterone antagonists, and peripherally acting adrenergic antagonists in patients with newly diagnosed hypertension. Caution is warranted in patients who are already stable on these therapies.
The Final Reasons of JNC8 is as follows :
1-The JNC 8 panel does not recommend first-line therapy with beta-blockers and alpha-blockers due to 1 trial that showed a higher rate of cardiovascular events with use of beta-blockers compared with use of an ARB

2-  and another trial in which alpha-blockers resulted in inferior cardiovascular outcomes compared with use of a diuretic.

In addition, a lack of evidence comparing the 4 first-line therapies with carvedilol, nebivolol, clonidine, hydralazine, reserpine, furosemide, spironolactone, and other similar medications precludes use of any medications other than ACEIs, ARBs, CCBs, and thiazide-type diuretics in the vast majority of patients.

One issue left secret in the world of evidence-based medicine; why they are preferring their very weak and not trusted evidence over expert opinion ,while
the “Expert Opinion” is the best evidenced for them in the absence of any evidence, otherwise . 

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