PubMed · 2863121
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A Shaughnessy. Comment: Exercise and beta-blockers.. https://doi.org/10.1177/106002808501900723
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BACKGROUND: Clinical practice guidelines (CPG) are thought to be an effective tool in improving efficiency and outcomes of clinical practice. Physicians' adherence to guidelines is reported to be poor. We evaluated the relationship between generalizability of guidelines on hypertension and physicians' adherence to guidelines' recommendations for pharmacological treatment. METHODS: We used the Sixth Joint National Committee's (JNC VI) guidelines on hypertension to evaluate our hypothesis. We evaluated the evidence from controlled clinical trials on which the JNC VI bases its recommendation, and compared the population enrolled in those trials with the American hypertensive population. Data on this population came from the National Health and Nutritional Examination Survey III. RESULTS: Twenty-three percent of the NHANES population had a diagnosis of hypertension, 11% had hypertension requiring drug treatment according to the JNC VI. Only half of the population requiring treatment would have been enrolled in at least two trials. Rate of adherence to CPG was 69%. We found a weak association between generalizability and physicians' adherence to guidelines. Baseline risk was the major determinant of the decision to treat. CONCLUSION: JNC VI guidelines may not be generalizable to their target population. We found a relatively poor adherence rate to these guidelines. Failing of completely taking into account the clinical characteristics of the patients may be partly responsible for this lack of adherence.
OBJECTIVES: We sought to examine the use and impact of standard medical therapies in patients with end-stage renal disease (ESRD) faced with an acute myocardial infarction (AMI). BACKGROUND: The poor prognosis of patients in this high-risk population has become increasingly well recognized. METHODS: Using the ESRD database and the Cooperative Cardiovascular Project (CCP) database, we identified AMI patients who were receiving either peritoneal dialysis or hemodialysis before admission. The early administration of aspirin and beta-blockers was compared between ESRD and non-ESRD patients and the effect of these therapies on 30-day mortality was evaluated with logistic regression models. RESULTS: The cohort consisted of 145,740 patients without ESRD and 1,025 patients with ESRD. Aspirin (67.0% vs. 82.4%, p < 0.001), beta-blockers (43.2% vs. 50.8%, p < 0.001), and angiotensin-converting enzyme (ACE) inhibitors (38.5% vs. 60.3%, p < 0.001) were less likely to be administered to ESRD patients than to non-ESRD patients. The benefit of these therapies on 30-day mortality was similar among ESRD patients (aspirin: relative risk [RR] 0.64; 95% confidence interval [CI] 0.50 to 0.80; beta-blocker: RR 0.78; 95% CI 0.60 to 0.99; ACE inhibitor: RR 0.58; 95% CI 0.42 to 0.77) and non-ESRD patients (aspirin: RR 0.57; 95% CI 0.55 to 0.58; beta-blocker: RR 0.70; 95% CI 0.68 to 0.72; ACE inhibitor: RR 0.64; 95% CI 0.63 to 0.66). CONCLUSIONS: End-stage renal disease patients are far less likely than non-ESRD patients to be treated with aspirin, beta-blockers, and ACE inhibitors during an admission for AMI. The lower rates of usage for these medications, particularly aspirin, may contribute to the increased 30-day mortality. These findings demonstrate a marked opportunity to improve care in this population.
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