No abstract

It is widely assumed in clinical practice that drug treatment associated with hypotension can result in falls and syncope, but there is actually very little evidence to support this. Therefore the data in all patients whose cardiovascular medications were stopped at a falls/syncope clinic were analysed to see if their symptoms were altered and if renewal of these medications was necessary at subsequent visits.Of 338 consecutive referrals, cardiovascular medications had been stopped in 65 (19%). At follow up 78% reported improvement in their original presenting symptoms and renewal of medication was not necessary in 77% oV antianginals, 69% oV antihypertensives, and 36% oV antiarrhythmics. It was concluded that adjusting cardiovascular medications could help in the management of falls and syncope and may obviate the need for other treatment. These medications can be stopped in select patients if there is regular monitoring and this should reduce unwanted side eVects and costs of these drugs. (Postgrad Med J 2001;77:403-405) Keywords: withdrawal of medications; falls; syncope Hypotensive responses are associated with recurrent falls and syncope and, a high prevalence of cardiovascular diagnoses in elderly fallers with and without syncope has been reported. 1 2 Some observational studies suggest that cardiovascular medications are associated with falls and syncope, 3-5 while casecontrol data refute this concept. 6 The main objectives of this study were to examine if patients attending a falls/syncope clinic reported any change in symptoms after their cardiovascular medications were adjusted, and to see if it was necessary to renew these drugs at follow up visits. Methods and resultsAll attendances at the syncope clinic in a two year period were reviewed noting those in whom cardiovascular drugs were deliberately stopped. Referrals to the clinic included those with recurrent unexplained falls and presyncope as well as syncope. Certain cardiovascular medications were stopped altogether if there was evidence of unwanted side eVects including a cardiovascular diagnosis attributable to their use, if there was no indication, that is, digoxin in those in sinus rhythm, and if supine blood pressure was <120/80 mm Hg in those taking antihypertensives.Twenty four hour ambulatory blood pressure monitoring (ABPM) was carried out after a six week period in all patients whose antihypertensive medications were stopped and at intervals thereafter in certain cases. The initial follow up visits were scheduled within a two month period and repeat visits were arranged at 2-3 month intervals for those needing ongoing review.Indications for restarting the medications at follow up visits were angina for antianginals and symptoms attributable to arrhythmias for antiarrhythmics. Three or more systolic blood pressure readings >160 mm Hg, three or more diastolic blood pressure readings >90 mm Hg, and/or a mean daytime blood pressure value >134/81 mm Hg 7 recorded during the 24 hour ABPM were considered indications to resume antihyp...

Background Studies have shown unwarranted variation in test ordering among GP practices and regions, which may lead to patient harm and increased health care costs. There is currently no robust evidence base to inform guidelines on monitoring long-term conditions. Objectives To map the extent and nature of research that provides evidence on the use of laboratory tests to monitor long-term conditions in primary care, and to identify gaps in existing research. Methods We performed a scoping review—a relatively new approach for mapping research evidence across broad topics—using data abstraction forms and charting data according to a scoping framework. We searched CINAHL, EMBASE and MEDLINE to April 2019. We included studies that aimed to optimize the use of laboratory tests and determine costs, patient harm or variation related to testing in a primary care population with long-term conditions. Results Ninety-four studies were included. Forty percent aimed to describe variation in test ordering and 36% to investigate test performance. Renal function tests (35%), HbA1c (23%) and lipids (17%) were the most studied laboratory tests. Most studies applied a cohort design using routinely collected health care data (49%). We found gaps in research on strategies to optimize test use to improve patient outcomes, optimal testing intervals and patient harms caused by over-testing. Conclusions Future research needs to address these gaps in evidence. High-level evidence is missing, i.e. randomized controlled trials comparing one monitoring strategy to another or quasi-experimental designs such as interrupted time series analysis if trials are not feasible.

Background We have shown previously that current recommendations in UK guidelines for monitoring long-term conditions are largely based on expert opinion. Due to a lack of robust evidence on optimal monitoring strategies and testing intervals, the guidelines are unclear and incomplete. This uncertainty may underly variation in testing that has been observed across the UK between GP practices and regions. Methods Our objective was to audit current testing practices of GPs in the UK; in particular, perspectives on laboratory tests for monitoring long-term conditions, the workload, and how confident GPs are in ordering and interpreting these tests. We designed an online survey consisting of multiple-choice and open-ended questions that was promoted on social media and in newsletters targeting GPs practicing in UK. The survey was live between October–November 2019. The results were analysed using a mixed-methods approach. Results The survey was completed by 550 GPs, of whom 69% had more than 10 years of experience. The majority spent more than 30 min per day on testing (78%), but only half of the respondents felt confident in dealing with abnormal results (53%). There was a high level of disagreement for whether liver function tests and full blood counts should be done ‘routinely’, ‘sometimes’, or ‘never’ in patients with a certain long-term condition. The free text comments revealed three common themes: (1) pressures that promote over-testing, i.e. guidelines or protocols, workload from secondary care, fear of missing something, patient expectations; (2) negative consequences of over-testing, i.e. increased workload and patient harm; and (3) uncertainties due to lack of evidence and unclear guidelines. Conclusion These results confirm the variation that has been observed in test ordering data. The results also show that most GPs spent a significant part of their day ordering and interpreting monitoring tests. The lack of confidence in knowing how to act on abnormal test results underlines the urgent need for robust evidence on optimal testing and the development of clear and unambiguous testing recommendations. Uncertainties surrounding optimal testing has resulted in an over-use of tests, which leads to a waste of resources, increased GP workload and potential patient harm.

EVIDENCE IN THE CONSULTATIONA 56-year-old attends his GP to discuss his newly diagnosed hypertension and asks the GP about the benefits and harms of taking long-term hypotensive medication … How accurate are we (GPs, healthcare professionals and other specialists) in providing this information?GPs are unlikely to have fingertip evidence knowledge for management decisions, but if we don't, should we? Treadwell et al 1 highlight GP inaccuracy in numerical assessment of benefits and harms of longterm medications used in several long-term conditions.