Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name's Dr Warrick Bishop and welcome to my podcast and videocast station. Today I'd like to talk about blood pressure medications taken at night and also fraudulent research and the effect or impact it can have on care. Well, this story is all about a trial that came out in 2019 called the HIGIA trial, H-Y-G-I-A. trial and hygeia or hygeia is greek for health so in the european heart journal in 2019 the hygeia trial was published it was a trial that included about 20 000 people with high blood pressure and those people were randomized to taking their blood pressure tablets in the morning or at night and the people who set up the trial wanted to see whether the theoretical reasons about taking blood pressure tablets at night were borne out in a clinical trial. And some of the reasons why we think blood pressure medication at night could be beneficial is that the body has cycles that it goes through over a 24-hour period. Things that we call circadian rhythms. Circular, circadian, relating to the day. rhythms where our cortisol levels change and our insulin levels change and our adrenal glands work differently and often is the case that in the morning as we're waking up there's a bit of a surge in some of the activity of these particular components of our metabolism and those surges seem to be linked to the observation or documentation. of the fact that we have increased episodes of heart attacks often early in the morning so the trial was set underway and it turned out the results were staggering with a 45 relative risk reduction in cardiovascular disease outcome really this was something to stand on a box about and shout and really would want all of us to be encouraging patients to be taking their blood pressure medications at night. So after the fanfare and the excitement and jubilation of this fantastic outcome and the opportunity to improve our care for our patients, unfortunately, some cracks started to appear. And it turned out that... as people looked in more detail into the study, that there were more and more concerns. Concerns about how the randomisation was undertaken, for example. The trial, although it was set up as a blood pressure trial and therefore should have been related to cardiovascular endpoints, solid cardiovascular endpoints like heart attack or stroke or death, Actually turned out that it had 15 primary endpoints, which suddenly sort of dilutes the accuracy of the intent of the intervention. There was a little bit of murkiness and a lack of clarity on the reporting of some of the complications within the trial and issues the patients had within there. It turned out that only 607 out of 19,000 odd patients were lost to follow-up. And in general terms, this is an extraordinarily low number. And so sometimes when something is said to be too good to be true, then perhaps it isn't true. Now, the other thing that raised people's concerns, and I have to say that the trial is still under investigation, so there's no final conclusions. But the other thing that raised eyebrows was that there was a greater 40%. in non-cardiovascular death. So that meant things like driving accidents, cancer, struck by lightning, murders. And when one thinks about it, it's very hard to propose a way that taking your blood pressure tablets at night could impact death from non-cardiovascular means. Having said all that, though, and having an awareness that there is some further evaluation of this particular trial, having said all that, can taking blood pressure tablets at night be beneficial? Well, I can certainly comment on that from a clinical perspective. And in my own experience, there's a couple of things that I think are worth noting. One is that for some people being organized, as part of their evening routine to take their tablets means that their adherence or their ability to stay on their medication is improved. So it might be as part of their evening ritual, brushing teeth, taking tablets, heading off to bed. So if taking tablets at night improves a patient's adherence and we know taking the tablets helps, then that's going to be to the good for that patient the other situation where i will often give medications at night is if we're using beta blockers it's not uncommon that beta blockers can make people feel fatigued and tired so to give an individual those sort of medications first thing in the morning we're setting them up potentially for a tired day but if we give them those medications at night then the fatigue may not be appreciated because the person's asleep and the drug levels may be low enough so that in the morning they're not affected by that particular consequence or action of the agent. The other thing is that sometimes if we want to get people's blood pressures down lowish if we give them medications in the morning then the peak level of those blood pressure medications will be in the bloodstream several hours after and lowering that person's blood pressure, possibly causing hypo, low hypotension. So low blood pressure. Well, often it's the case I'll give people blood pressure tablets at night so that we can drive their blood pressures down overnight without driving them down too much during the day when they're standing up and walking around and reducing that risk of postural hypotension or low blood pressure. So while we wait for the high gear trial to be evaluated further, my own practice is that in certain situations, giving you blood pressure tablets at night makes a bit of sense. I hope that makes sense to you. I hope you've learned a little bit. If you have any queries or questions, please drop us a line. I'm going to wish you the very best. Until next time, thank you for joining us. Take care. Bye for now. And please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
