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Section III
REASONING IN BIOLOGICAL AND PHYSICAL SCIENCES
UNIT 1
Questions 1 -
5
ACE inhibitors are Better First Choice than Diuretics for Elderly
Patients, study says.
Some doctors are criticising a recent government
sponsored clinical trial that found diuretics to be the best first option for
treating high blood pressure in elderly people. Critics say the results from
the 10 year study, known as ALLHAT (the antihypertensive and lipid lowering to
prevent heart attack trial) and published in December to wide publicity,
overstated the case for diuretics and contradicted clinical experience. These
critics are getting some backing from a new study published this week in the
New England Journal of Medicine, which suggests that angiotensin converting
enzyme (ACE) inhibitors are a better first choice for older patients, leading
to fewer deaths, heart attacks, strokes, and other cardiovascular problems. In
the trial 6083 people with hypertension who were aged 65 to 84 years were
randomly assigned to either the diuretic hydrochlorothiazide or the ACE
inhibitor enalapril and followed for a median of 4.1 years.
The
seemingly conflicting reports also underscore the difficulty of using evidence
from major studies to standardise medical treatment. "Both of these studies are
very good, and they're coming out with important information," said Edward D
Frohlich of the Ochsner Clinic Foundation in New Orleans and author of an
editorial accompanying the new study. "But they're only to provide guidelines.
The only thing that's going to tell a physician which drug to use is the
patient and his or her response to therapy," he added.
In the ALLHAT
trial, which tested calcium channel blockers in addition to ACE inhibitors and
diuretics, no difference in the number of heart attacks or cardiac related
deaths was found. But ALLHAT patients on diuretics had better blood pressure
control, fewer strokes, and less congestive heart failure, among other
benefits.
The two studies are not directly comparable. The ALLHAT trial
included patients as young as 55, and about 35% of ALLHAT patients were
African-American, and thus thought to be particularly responsive to diuretics.
In both studies, most patients ended up taking more than one drug. In ALLHAT,
the researchers tried to make sure that patients started on an ACE inhibitor
did not also get a diuretic. In the new study, there was considerable
crossover: 25% of patients taking a diuretic eventually also took an ACE
inhibitor, and vice versa. In addition, the two studies used different types of
diuretics and ACE inhibitors.
Dr Frohlich warns that treatment of the
individual patient with hypertension is complicated, requiring time and
judgment.
Question 1
Drugs such as hydrochlorothiazide
cause the production of
A A large volume of concentrated urine
B A large volume of dilute urine
C A small volume of
dilute urine
D A small volume of concentrated urine
Question 2
The number of patients in the new study who
took diuretics and ACE inhibitors together at some point in the study was
A 50%
B 25%
C 100%
D 75%
Question 3
ACE inhibitors would cause
A A
decrease in the production of angiotensin II
B An increase in the
production of angiotensin I
C A decrease in the effect of
angiotensin I
D An increase in the effect of angiotensin II
Question 4
"In addition, the two studies used different
types of diuretics and ACE inhibitors." This may invalidate comparisons between
the studies because
A Different Diuretics have different sites
of action
B Different ACE inhibitors act on different enzymes
C Diuretics have greater effects in Afro-Americans
D No
Calcium-Channel blockers were used in one study
Question 5
"Treatment of the individual patient with hypertension is complicated,
requiring time and judgment." This is because
A Patients respond
differently to the same drug
B Hypertension is a multi-factoral
condition
C Hypertension is a chronic condition
D ACE
inhibitors are a better first choice drug in cases of hypertension in the
elderly
SECTION
ANSWERS
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