Second Australian National Blood Pressure Study
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Second Australian National Blood Pressure Study
Conducted by the High Blood Pressure Research Council of Australia in conjunction
with Australia’s General Practitioners
ANBP2
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Background
• Treatment of hypertension based on diuretics and/or beta blockers provides a definite outcome benefit
• Additional benefit beyond that resulting from blood pressure reduction may result with therapy based on agents inhibiting the renin-angiotensin system
ANBP2New Engl J Med, 2003;348:583-92.
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Antihypertensive Drug Use in Australia
Hypertension Patient Numbers 1993-98
0
100000
200000
300000
400000
500000
600000
70000019
93
1994
1995
1996
1997
1998
Patie
nt n
umbe
rs (
Hyp
erte
nsio
n)
Diuretics
Beta Blockers
Calcium ChannelBlockers
ACE Inhibitors
Angiotensin IIAntagonists
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Background
• No outcome data with ACE inhibitor based regimens• Potential benefits include
– Reduction in LVH– Improved survival with cardiac failure– Enhanced insulin sensitivity– Lipid “neutrality”
Will outcome be the same better or worse than those of published studies?
ANBP2
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Main Aim
To determine in hypertensive patients aged 65-
84 years whether there is any difference in
total cardiovascular events (fatal and non-
fatal) over a 5 year treatment period between
treatment with either a diuretic-based
regimen or an ACE inhibitor-based regimen
ANBP2New Engl J Med, 2003;348:583-92.
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Study Design
P prospective
R randomised
O open label
B blinded
E endpoints
Features• Intention to treat• General practice based• 600 practices• 6000 patients• Recruitment: 2.5 years
ANBP2New Engl J Med, 2003;348:583-92.
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ANBP2
National Centre (BMRI)
ManagementCommittee(HBPRCA) Sub Committees
General PracticeData monitoringEnd - pointAuditSubstudies: ABPM, LVH,Genetic, Health Econ
Regional Centers
SA QLDVIC NSW
WA
Data ManagementCentre
(Uni of Adelaide)
Study Organisation
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Study SubjectsInclusion Criteria
• Men and women 65 - 84 years• Previously treated or newly diagnosed hypertensives • Untreated sitting SBP > 160 and/or DBP > 90 mmHg• Able to give consent and to attend GP practice• No recent cardiovascular morbidity
ANBP2
Exclusion Criteria• Any cardiovascular end-point in the past 6 months• Dementia• Plasma creatinine > 0.2 mmol/L• Any life threatening illness (unlikely to survive 5 years)• Unwillingness of GP to enter subject into study• Unable to attend GP practice• Absolute contraindication to ACE or diuretic
New Engl J Med, 2003;348:583-92.
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Study Protocol• Blood Pressure Screening
• 3 visits conducted by Study Nurses• 3 measurements (average of 2nd and 3rd)• Mercury sphygmomanometer• Entry BP - average of 2nd and 3rd visit readings
• Randomisation• Central - Data Management Centre (Adelaide)• Stratified for age (> or 75)
• Follow-Up• GP manages patient according to usual practice• Conform (where possible) to randomisation arm• Achieve subject goal BP• At least 2 visits per year
ANBP2New Engl J Med, 2003;348:583-92.
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Study Drug Treatments
• ACE Inhibitor Group• Step 1. ACE Inhibitor (enalapril recommended)• Step 2. Beta or alpha blocker or calcium antagonist• Step 3. Drug from class not used in Step 2 or diuretic• Step 4. Drug from class not used in step 2 or 3
• Diuretic Group• Step 1. Thiazide type diuretic (low dose)• Step 2. Beta or alpha blocker or calcium antagonist• Step 3. Drug from class not used in Step 2• Step 4. Drug from class not used in step 2 or 3
ANBP2New Engl J Med, 2003;348:583-92.
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Study End-points
• Obtained by study nurses from GP case notes, hospital case records and death certificates
• End-point Committee (blinded to treatment allocation) evaluated all data relating to potential study end-points
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• Primary Outcome: All cardiovascular events (initial and subsequent) or death from any cause – ‘total burden of cardiovascular disease’
• Any first event or death – ‘event-free survival’• Cause-specific first events
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End-points
• myocardial infarction (fatal and non-fatal)• sudden or rapid or ‘other’ cardiac death• coronary events resulting in coronary therapeutic
procedures• cardiac failure (fatal or non-fatal)• stroke (fatal or non-fatal)• transient cerebral ischaemic attacks• acute non-coronary or non-cerebral vascular
occlusion • other vascular deaths• dissecting or ruptured aortic aneurysm
ANBP2New Engl J Med, 2003;348:583-92.
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Data Analysis
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• Multivariate proportional hazards (Cox) models incorporating:– Wei-Lin-Weissfeld method for multiple failure time data– Li-Lagakos application of WLW method to analyse recurrent
event data with a terminating event– Robust variance estimation– Validation by simulation
• Proportional hazards (Cox) models for cause-specific first events
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ANBP2
GP Involvement in ANBP2
390270
500299
472224
958601
361200
2681 - GPs 1594 - Practices
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146691310 9%
7530 84911%
7607 672 9%
744876310%
17145248915% ANBP2
ANBP2 Subject Recruitment
Screened - 54288Randomised - 6083Rate - 11%
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Study profile54288
screened25805 ineligible16899 unwilling to participate5501 did not meet inclusion criteria
6083randomised
ACE3044
Diuretic3039
0 No Vital Status 2
ACE3044
Diuretic3037
ITT* analysis
ANBP2* Intention to treat
Observation Time
Median 4.1 yrs
Patient yrs 24702
~ 3 yrs
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Baseline data
ANBP2
ACE Diuretic(3044) (3039)
Male: Female 50:50 48:52
Age (yr) 72.0 71.9
Blood Pressure (mmHg) 167 ± 13 168 ± 13 91 ± 8 91 ± 8
Previously Treated 62% 62%
Body Mass Index (kg/m2) 27 ± 4 27 ± 4
Current Smokers 7% 7%Physically Active 78% 76%
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Baseline data
ANBP2
ACE Diuretic(3044) (3039)
Coronary Heart Disease 8% 8%
Cerebrovascular Disease 5% 5%
Diabetes Mellitus 8% 7%
Hypercholesterolaemia 38% 36% - lipid lowering drugs 13% 13%
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Drug treatments
ANBP2
At Randomisation At Study EndACE Diuretic ACE Diuretic(3044) (3039) (3044) (3039)
Allocated Therapy 83% 83% 58% 62%
Monotherapy 82% 82% 65% 67%
3 agents 6% 5%
No drugs 16% 15% 4% 3%
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Antihypertensive Medication Use at Study End
ANBP2
ACE Diuretic
ACE 58 18
Beta Blocker 11 14
Ca Blocker 23 25
Diuretic 24 62
Single Drug 65 67
2 Drugs 25 25
3 + Drugs 6 5
Data represent %
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Blo
od P
ress
ure
(mm
Hg)
75
80
85
90
95
130
140
150
160
170
Years Since Randomization
0 1 2 3 4 5
ACEDiuretic
Systolic
Diastolic6083
6035 5583 5487 4320 1183
6083
6035 5585 5487 4323 1183
In-study blood pressure
ANBP2
-26 mmHg
-12 mmHg
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Primary Result
ANBP2
ACE Diuretic Event n Rate n Rate HR (95%CI) p
All cardiovascular 692 55.8 732 59.5 0.89 (0.79,1.00) 0.05 events or any death
First cardiovascular 490 41.9 529 45.7 0.89 (0.79,1.01) 0.06 event or death
Death 195 15.7 210 17.1 0.90 (0.75,1.09) 0.27
Rate per 1000 patient years
Adjusted for age, gender
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Primary Result
ANBP2Rate per 1000 patient years
Adjusted for age, gender
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Hazard Ratio (95% CI) p ACE better Diuretic better0.2 1.0 5.0
Cardiovascular 0.88 (0.77,1.01) 0.07
Non-Fatal Cardiovascular 0.86 (0.74,0.99) 0.03
Cerebrovascular 0.90 (0.73,1.12) 0.35
Stroke 1.02 (0.78,1.33) 0.91
Coronary 0.86 (0.70,1.06) 0.16
Myocardial Infarction 0.68 (0.47,0.98) 0.04
Other Cardiovascular 0.90 (0.71,1.14) 0.36
Heart Failure 0.85 (0.62,1.18) 0.33
Cause-specific first events
ANBP2All subjects - first any events
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Hazard Ratio (95% CI) p ACE better Diuretic better0.2 1.0 5.0
Cardiovascular 0.99 (0.72,1.35) 0.94
Non-Cardiovascular 0.84 (0.66,1.08) 0.18
Cancer 0.98 (0.73,1.32) 0.89
Trauma 2.87 (0.31,26.9) 0.36
Other Non-Cardiovascular 0.57 (0.37,0.90) 0.01
Stroke 1.91 (1.04,3.50) 0.04
Coronary 0.74 (0.49,1.11) 0.14
Myocardial Infarction 0.79 (0.31,1.99) 0.61
Other Cardiovascular 0.95 (0.46,1.96) 0.89
Heart Failure 0.24 (0.03,1.94) 0.18
Cause-specific fatal events
ANBP2All subjects - fatal events
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Hazard Ratio (95% CI) p ACE better Diuretic better0.2 1.0 5.0
Stroke 0.93 (0.70,1.26) 0.65
Coronary 0.92 (0.73,1.16) 0.49
Myocardial Infarction 0.68 (0.47,0.99) 0.05
Other Cardiovascular 0.84 (0.66,1.07) 0.17
Heart Failure 0.85 (0.62,1.17) 0.32
Cause-specific non-fatal events
ANBP2
All subjects - first non-fatal events
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Summary
• 11% reduction in total cardiovascular events (or death from any cause) with ACE inhibitor treatment
• 11% reduction in first events with ACE inhibitor treatment
• 17% reduction in total events in males and no effect in females
ANBP2New Engl J Med, 2003;348:583-92.
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Summary
• No difference between treatments– total or cardiovascular mortality– all cerebrovascular events– all coronary events
• With ACE inhibitor treatment– reduction in first non-fatal cardiovascular events
(HR 0.86)– reduction in non-fatal myocardial infarctions (HR
0.68)– increase in fatal strokes (HR 1.91)– cause-specific effects only in males ANBP2
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Conclusion
Initiation of antihypertensive treatment in older patients with an ACE inhibitor particularly in males has a modest but definite outcome advantage over a diuretic despite a similar
reduction in blood pressure
ANBP2New Engl J Med, 2003;348:583-92.
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Acknowledgments
• Australian Commonwealth Department of Health and Ageing
• National Health and Medical Research Council of Australia
• Study staff• Australia’s General Practitioners• Merck Sharp & Dohme (Australia) Pty Ltd
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Acknowledgments
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Prof L. Wing (SA - Chairperson)
Dr C. Reid (Vic - Study Director)
Dr P. Ryan (SA - Statistician)
Prof G. Jennings (Vic)
Prof J. McNeil (Vic)
Prof M. Brown (NSW)
Prof C. Johnston (Vic)
Prof T. Morgan ( Vic)
Prof J. Marley (SA)
Prof L. Beilin (WA)
Prof M. West (Qld)
Prof G. MacDonald (NSW)
ANBP2Management
Committee
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Acknowledgments
ANBP2
Regional Co-ordinating Centres:
Mark Nelson, Anne Bruce, Paul Beckinsale, Jill Thompson, Marilyn McMurchie,
Glenda Fraser, David Gleave, Vicki Cope, Fred DeLooze, Sue Moore,
Cathy Dibben, Jonathon Newbury
Data Management and National Coordinating Centres:
Helen Miles, Brian McDermott, Kristyn Willson, Carol Bear
Genetic Sub-Committee:
Malcolm West, Stephen Harrap, Colin Johnston, Lawrie Beilin, Philip Ryan,
Lindon Wing, Christopher Reid
Ambulatory Blood Pressure Monitoring Sub-Committee:
Lawrie Beilin, Mark Brown, Philip Ryan, Lindon Wing, Christopher Reid
LVH Sub-Committee:
Garry Jennings, Peter Fletcher, Michael Feneley, Elizabeth Dewar, Lindon Wing,
Christopher Reid
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Acknowledgments
ANBP2
Data Audit Sub-Committee:
John McNeil, Lindon Wing, John Marley, Christopher Reid
Finance Sub-Committee:
Colin Johnston, Garry Jennings, Lindon Wing, Christopher Reid
Health Economic/Quality of Life Sub-Committee:
John Marley, John Moss, Penny Webb, Paul Glasziou, Fran Boyle, John Primrose,
Lindon Wing, Christopher Reid
GP Advisory Committee: Ian Steven, Leon Piterman, Fred De Looze,
Jim Dickinson, John Gambrill, Peter Joseph, Christopher Reid
End-point Committee: David Hunt, Geoff Donnan, Lindon Wing, Trefor Morgan
Independent Data Audit Sub-Committee: John Chalmers,
Judith Whitworth, Stephen MacMahon, Chris Silagy (Decd)