BMJ 2014;348:g1788 doi: 10.1136/bmj.g1788 (Published 27 February 2014)

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RESEARCH NEWS Geriatrician questions prescribing for stroke prevention in people over 80 Zosia Kmietowicz BMJ

People in their 80s are being overtreated for the prevention of stroke with statins and antihypertensives, whose benefit is marginal at best, an article in the journal Evidence Based Medicine has claimed.

Kit Byatt, a geriatrician at the County Hospital in Hereford, said that doctors “need actively to rethink [their] priorities and beliefs about stroke prevention” among this age group.1 He said research showed that among people in their 80s high blood pressure was not a key contributory risk factor for stroke and that high cholesterol concentrations had little effect on the overall risk of stroke. However, statins and antihypertensives are widely used in this group of patients to prevent stroke.

favour of taking fewer drugs every day and not having to put up with their possible side effects.

“The data strongly suggest that we are overtreating many healthy patients aged 80 plus regarding stroke prevention,” concluded Byatt. And he questioned whether these drugs should ever be used in frail older patients with several underlying conditions. “We need actively to rethink our priorities and beliefs about stroke prevention, actively informing and involving the views of the key person, the patient,” he said.

Data from the HYVET (Hypertension in the Very Elderly Trial) study—which many consider the definitive antihypertensive trial in older people and which involved 4000 patients—yielded a number needed to treat (NNT) in excess of 450 over two years for the prevention of non-fatal stroke. Even for fatal or non-fatal cardiac failure the NNT was in excess of 50 over two years. Similarly, the PROSPER study of statins for stroke prevention, which involved nearly 6000 people aged 70-82, found no statistically significant reduction in stroke, and the relative risk reduction of all cardiovascular endpoints of 33% gave a crude NNT of 59 over three years.

Byatt argued that older patients had diverse views on the relative importance of stroke and death as endpoints, which differed from clinicians’ beliefs. Many “would rather die than end up incapacitated by a stroke,” he said. He added that most older patients would probably reject the modest potential benefit from statins and antihypertensives in

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1

Byatt K. Overenthusiastic stroke risk factor modification in the over 80s: are we being disingenuous to ourselves, and to our oldest patients? Evid Based Med 27 Feb 2014, doi:10.1136/eb-2013-101646.

Cite this as: BMJ 2014;348:g1788 © BMJ Publishing Group Ltd 2014

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Geriatrician questions prescribing for stroke prevention in people over 80.

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