While it is driving sophisticated scientific advances and becoming increasingly more precise in dealing with diseases that were once incurable, medicine is also trying to resolve historic debates that, although they may seem minor, actually influence the health of millions of people. A good example is the one that has surrounded for years the treatment of high blood pressure, an illness that affects a third of people between 30 and 79 years old in Spain (10 million), of whom 57% take medication, according to a study. recent study published by the Spanish Journal of Cardiology.
“The question we have been facing all this time is whether it is better to take a pill for blood pressure in the morning or at night,” summarises the president of the Spanish Society of Cardiology (SEC), Luis Rodríguez Padial, who is also head of the department of the specialty at the University Hospital of Toledo. The debate, he adds, has been greatly influenced in the last decade by so-called chronotherapy, a discipline that seeks to improve the effectiveness of treatments by adapting them to the changing biological rhythms of the body during the day.
The controversy has now been definitively resolved at the recent congress of the European Society of Cardiology, held last week in London (United Kingdom)And the answer, after so many years of arguments in favour of one option or another – although with greater support for taking it at night – is somewhat disappointing: the game is a draw. “The truth is that, in the end, it doesn’t matter when you take it. The important thing is to do it every day and maintain healthy lifestyle habits,” says Rodríguez Padial.
Enalapril and losartan are two of the most commonly prescribed drugs for treating hypertension. The first is an angiotensin-converting enzyme inhibitor (ACEI) and the second is an angiotensin 2 receptor antagonist (ARB), which also includes valsartan. A third group of drugs used are the so-called calcium antagonists. “The usual practice, unless an increase in medication is required, is to prescribe one of these three types of drugs together with a low-dose diuretic,” explains Manuel Anguita, head of the Clinical Cardiology section at the Reina Sofía Hospital in Córdoba and spokesperson for the SEC.
Scott Garrison of the University of Alberta (Canada) summed up the findings in London with the following statement: “We found that there is no difference between taking the medication at bedtime or in the morning in terms of the risk of serious cardiovascular events.” This doctor is the principal investigator of the two works presented at the congress that have definitively settled the question.
“One of them is with younger people, with an average age of 62 or 63 years.and the other with much older and more fragile patients. The result has been the same: the incidence of cardiovascular events in the medium and long term is the same whether taking the medication in the morning or at night,” says Manuel Anguita. These conclusions have been confirmed by a meta-analysis presented at the congress.
Antonio Bascuñana is 78 years old and has five children. After a long working life, first as an insurance inspector and then as the head of a tobacco shop, it was after retiring that he was diagnosed with hypertension. “I have always been very active, I really liked running the business and not stopping all day, so retirement changed my life completely. I think that had something to do with my ending up being hypertensive,” he reflects. In his case, the family doctor initially told him to take the pill in the morning, and it has worked well for him – it is easy for him to remember and follow the treatment – and he has not made any changes.
Miguel Ángel María Tablado, coordinator of the Arterial Hypertension group of the Spanish Society of Family and Community Medicine (semFYC), maintains that the debate on the time at which to take the pill – more bitter among specialist doctors such as cardiologists – is somewhat diluted in primary care consultations. “It is true that until now there were studies that indicated that it was better to do it at night, but in my opinion it was not very robust evidence either. Each patient is different, we know them well and there are other factors that influence it,” he says.
One of them is the objective of improving adherence, that is, getting the patient to comply better with the treatment. If it is easier for him to remember that he has to take the pill in the morning before breakfast – or at any other time or in any other way – and there is no very solid evidence that leads to changing this pattern, it is better to continue with it. The president of the Spanish cardiologists insists on the idea: “Sometimes doctors give patients complicated treatment guidelines and the only thing we achieve is that they forget to comply with them. The best effectiveness against blood pressure is achieved by taking the pill every day, so the easier we make it for them, the better.”
Miguel Medina, 66, illustrates the importance of routines: “I have been taking losartan with a diuretic for 10 years. [hidroclorotiacida] “I take it every morning. In all this time they have never changed my medication and I have not had any problems. Except for two times when I have had high blood pressure crises. Both times have been on vacation and away from home. And with all the changes that this entails, the truth is that I don’t know if I had taken the pills correctly or not,” says this retired security guard, who has four children.
Miguel Ángel María Tablado explains another reason that may lead doctors to recommend taking it in the morning. “These treatments almost always include a diuretic. And this, for many people, especially older men, can be a problem because they spend the night going to the bathroom to urinate and do not rest well,” he adds.
In the long debate about when it is best to take the blood pressure pill, it was a Spanish study that gave the most arguments —five years ago, although now they have been questioned— to recommend that patients take it at night. The work, part of the so-called Hygia Project, It was carried out by primary care physicians and researchers from the University of Vigo and its conclusions were published in the European Heart Journalthe most influential cardiology journal in the world.
After analyzing data from 19,000 patients, the authors concluded that by taking the pill at night, “the risk of death from cardiovascular problems was reduced by 66%, the risk of a myocardial infarction by 44%, coronary revascularization by 40%, heart failure by 42% and the risk of a stroke by 49%,” according to the press release published at that time by the Xunta de Galicia.
“The study had a huge impact because the results were spectacular. Soon, however, some methodological aspects began to be questioned, so the debate became a bit open again. A year and a half ago, another study in the United Kingdom, called TIME, “He made the same comparison between taking the morning dose and taking it before bed. And there they saw no differences in terms of events or cardiovascular disease. In other words, the conclusions contradicted the previous study, so the matter remained even more up in the air. Now, finally, we have the definitive answer,” says Manuel Anguita.
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