Author: Dr Andrew Borrie
I recently attended the European Society of Cardiology Congress in London, which was an excellent meeting with presentation of some practice changing trials and guidelines.
BedMed: it doesn’t matter what time you take blood pressure medications
Timing of administration of blood pressure medications has been controversial. Blood pressure follows a circadian rhythm, with peaks on waking and lowest values during sleep. Lack of BP decline during sleep (“non-dipping”) is associated with major adverse cardiovascular events. This led to a series of trials examining the timing of medications.
The MAPEC (2010) and Hygia (2019) trials showed improved outcomes with bedtime administration, however there were concerns about the quality of these trials. The TIME trial (2022) showed no difference.
The BedMed (1) and BedMED-Frail (2) trials aimed to settle this controversy. BedMed and BedMed Frail enrolled patients on at least one blood pressure medication, in the community and in rest home residents respectively. They randomised patients to morning or evening medication and followed them for up to 6 years.
There was no difference in the primary and secondary outcomes of stroke, heart attack, heart failure, death, hospital visits, falls, fractures, cognition, behaviour, vision and urinary incontinence.
Take away message: blood pressure medications should be taken whenever you are least likely to forget them!
As a side note, the same goes for newer statins (atorvastatin and rosuvastatin) (3).
SHAM-PVI and ESC 2024 AF guidelines: Pulmonary vein isolation ablation is now recommended as first line treatment for AF
Multiple trials have established the role of ablation for atrial fibrillation, however the role of a placebo effect has been queried. The SHAM-PVI trial (4) was a randomised trial comparing pulmonary vein isolation ablation (PVI) to a sham procedure where catheters were inserted into the heart, but no ablation was done. Patients did not know if they had received the treatment or sham procedure.
PVI showed a 75% reduction in AF burden compared to sham procedure, secondary outcomes of quality of life and symptom scores were strongly in favour of ablation. There were no complications in the 62 patients in the ablation arm.
This trial supports the use of ablation for atrial fibrillation, and at the same meeting the 2024 ESC AF guidelines (5) were released. Catheter ablation is now recommended as the first line option for patients with atrial fibrillation, with a level of evidence of 1A (the highest level).
This recognises the high efficacy of ablation, and that in the long term it has a more favourable safety profile compared to anti-arrhythmic drugs, which have a 1-2% rate of serious arrhythmia per year. Practice in New Zealand will be interesting to watch, as despite this strong recommendation, with current resources it will be difficult to provide ablation as first line treatment in the public health system.
Take away message: Ablation is now recommended as the first line treatment for AF in suitable patients.
References and Further Reading
- Garrison SR, Kolber MR, Allan GM, Bakal J, Green L, Singer A, et al. Bedtime versus morning use of antihypertensives for cardiovascular risk reduction (BedMed): protocol for a prospective, randomised, open-label, blinded end-point pragmatic trial. BMJ Open. 2022 Feb 24;12(2).
- Garrison SR, Youngson E, Perry DA, Campbell FN, Kolber MR, Korownyk C, et al. Bedtime versus morning use of antihypertensives in frail continuing care residents (BedMed-Frail): protocol for a prospective, randomised, open-label, blinded end-point pragmatic trial. BMJ Open [Internet]. 2023 Aug 1 [cited 2024 Sep 27];13(8). Available from: https://pubmed.ncbi.nlm.nih.gov/37527898/
- Awad K, Banach M. The optimal time of day for statin administration: a review of current evidence. Curr Opin Lipidol [Internet]. 2018 [cited 2024 Sep 27];29(4):340–5. Available from: https://pubmed.ncbi.nlm.nih.gov/29771699/
- Dulai R, Sulke N, Freemantle N, Lambiase PD, Farwell D, Srinivasan NT, et al. Pulmonary Vein Isolation vs Sham Intervention in Symptomatic Atrial Fibrillation: The SHAM-PVI Randomized Clinical Trial. JAMA [Internet]. 2024 [cited 2024 Sep 27]; Available from: https://jamanetwork.com/journals/jama/fullarticle/2823283
- Van Gelder IC, Rienstra M, Bunting K V, Casado-Arroyo R, Caso V, Crijns HJGM, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 Aug 30;