Preventing Hypertensive Stroke

     This blog is rather short, because the basic facets and results are quite clear. The biggest risk factor for stroke in the general public is high blood pressure. The first anti-hypertensive to conclusively demonstrate a reduction in stroke risk was thiazide diuretics. They apparently work by lowering the total amount of salt in the body. We also know that thiazide diuretics are synergistic with every other anti-hypertensive medicine, in that diuretics potentiate the effect of every other hypertensive treatment. In fact, if you are on two anti-hypertensive drugs, one of them should be a diuretic, unless you have some very unusual medical condition.

     So the message of this blog is that diuretics prevent strokes. I raise this point because recent medical studies have been trumpeted in the newspapers as being more effective or more potent than thiazides in lowering blood pressure. But the question to ask your doctor is if this new and "better" anti-hypertensive treatment has been shown to lower the risk of stroke. If it hasn't, then either ask him to add a diuretic,  or see a specialist in hypertension, to see if yours is a special case.

     This is a small example of substituting an endpoint for a clinical result. We have seen similar problems in whether or not lowering cholesterol prevents heart attacks, or if lowering CPR is beneficial. To use my favorite analogy, just because you have a better "tool" for returning the arrow over the elevator to the lobby than simply pushing the lobby button, it doesn't mean that your tool will get the elevator down any faster.

OTC Phenypropylamine---increased stroke risk

A friend of mine forwarded me a brief letter which I feel deserves the widest possible circulation.



There were originally two over-the-counter (vascular) decongestants that were sold for relief of the symptoms of the common cold: phenylpropylamine, and pseudoephedrine. Of the two, phenylpropylamine was observed to cause a more severe vascular constriction in the cerebral circulation, and a statistically significant increase in the incidence of strokes in patients NOT OTHERWISE AT CVA RISK was noted. This was of especial significance in women and children, and so gradually fewer and fewer OTC "cold pills" contained phenylpropylamine. For instance, the popular decongestant Sudafed contained only pseudoephedrine.



Several years ago, the government noted that bathtub chemists were "cooking" psudoephedrine (with acetone, I think) to make methamphetamine, aka "speed" or "crank". The government therefore strongly discouraged the use of OTC pseudoephedrine, and now in some states it is kept behind the drug store's counter, or you have to sign for it, or the amount you can buy is limited.



However, post-marketing studies, as reported in the FDA's surveillance bulletin, have again noticed an increase in strokes associated with the use of phenylpropylamine. Therefore I have send a letter to all of my patients: DISCARD ALL COLD TABLETS CONTAINING PHENYLPROPYLAMINE, and never buy such tablets, either OTC or by prescription. This warning also applies to nasal sprays.



I would hope all my readers follow this advice (and please check with your doctors to notify them of your action and your reason for it).

The FDA link is: http://www.fda.gov/cder/druginfopage/ppa