Homework

You have a 72 year-old woman in your office for a routine checkup. She is generally healthy, except for some mild osteoarthritis for which she takes acetaminophen. Her blood pressure is 190/84. Your office nurse teaches her to take her own blood pressure. Her blood pressure readings correlate well with those of your nurse.

She returns two weeks later with her readings. The range is 160 to 210 systolic and 72 to 96 diastolic. Her average blood pressure is 193/88. You confirm that she is not taking any anti-inflammatory agents, decongestants or other sympathomimetic drugs.

We are faced with a number of potential clinical issues:

• Could this patient have renovascular hypertension?
• Does she need to be treated?
• Will she be better off being treated?

Since this is not the diagnostic module or the module on prognosis, we'll ignore the first two issues! Before we can proceed, we really need to have a better question to answer. Before moving on write down on a separate piece of paper 2 or 3 questions related to therapy for this patient scenario.

A global question, such as "How should I treat systolic hypertension in the elderly" is a good starting point but still needs more focus. A more focused question might be "Are patients better off if we treat isolated systolic hypertension?" An even more focused question might be "Is active therapy better than placebo in reducing all-cause mortality, cardiovascular mortality, and cardiovascular end points in isolated systolic hypertension (ISH) in the elderly?" This last question has four parts to it:

1. The patient and problem (ISH in an elderly woman)
2. The intervention (active therapy)
3. The comparison intervention (placebo)
4. The outcomes of interest (mortality and morbidity).

To answer this question, we need to search for it! A common source of answers comes from MEDLINE. The PUBMED website is a nice free resource (your tax dollars at work) and the MEDLINE source for the next step.

Use the following terms:

"hypertension"[MeSH Major Topic] AND ("aged"[MeSH Terms] OR "aged, 80 and over"[MeSH Terms]) AND "randomized controlled trial"[Publication Type] AND "mortality"[MeSH Terms]

You should get about 41 "hits". You can scan the titles quickly and see that only a few look particularly relevant. For this exercise, we will use the following article:

SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991 Jun 26;265(24):3255-3264

Get a copy of it! Print the worksheet, and use it as a guide to critically reading the paper. Once you have done that (and not before!) take a look at our critical appraisal of this article.  Be sure you calculate NNTs for the key outcomes.  A separate table lists the ARR and NNT for the major outcomes in this article.