Hypertension and stroke--rationale behind the ACCESS trial. Acute Candesartan Cilexetil Evaluation in Stroke Survivors.

Antihypertensive treatment achieves its greatest benefit in the primary prevention of stroke. Primary prevention studies show 38% fewer strokes when systolic/diastolic values are reduced by 10-12/5-6 mmHg. Secondary stroke prevention has been less investigated, but restrokes seems to be reduced with antihypertensive treatment. Secondary prevention achieves 25-30% less strokes, if diastolic BP can be reduced by 3-4 mmHg. Today's guidelines for antihypertensive therapy in acute ischemic stroke suggest reducing BP values over 220 mmHg systolic (AHA) or 200/110 (German Hypertension Society). No data are available about antihypertensive treatment in acute stroke patients. No intervention trials have so far evaluated an immediate BP reduction on the clinical outcome of the patients neurological status (morbidity) or mortality rates in the acute stroke situation. However, some studies show an increase in mortality after a quick and rapid BP reduction in a short time interval. The ACCESS study was designed to evaluate the possible benefits of a careful and moderate, but immediate blood pressure reduction in patients with an acute stroke compared to a restrictive antihypertensive therapy. Candesartan cilexetil was selected as the antihypertensive drug for its slow onset of action and moderate BP reduction, as well as its very good tolerability. Experimental studies point at possible advantages in acute stroke. The study was designed as a prospective, randomized, double-blind, placebo-controlled, multicenter trial (500 patients). Inclusion criteria were an acute ischemic stroke with a motor paresis and severe hypertension. Primary endpoints were the patients morbidity (functional status measured with Rankin and Barthel index, degree of motor deficity by NIH scale) and mortality rates after three months. First results are presented.

Panic disorder - acceptance of the diagnostic entity and treatment modalities preferred by German health professionals.

A survey of the pharmacological and psychological treatment of panic disorder and agoraphobia (PDA) was conducted among 103 physicians, psychologists and psychotherapists. It revealed that the treatments for PDA preferred by the majority of the respondents are inconsistent with the recommendations given in the international literature. Non-psychiatric physicians most frequently proposed herbal preparations as a possible treatment (46% of non-psychiatric physicians), followed by homoeopathic formulations (32%). Tricyclic antidepressants which are recommended as first-line treatment in panic disorder by the literature are preferred by 74% of the psychiatrists, but only by 24% of the non-psychiatric physicians. Benzodiazepines are prescribed by twice as many psychiatrists (45%) as non-psychiatric physicians (22%). Beta blockers and neuroleptics which are not recommended as first-line treatment in panic disorder are used quite often (psychiatrists: 15%; non-psychiatric physicians: 26%). Selective serotonin reuptake inhibitors are prescribed by 24% of the psychiatrists, but by only 3% of the non-psychiatric physicians. Among psychological therapies, psychoanalysis was proposed as first-line treatment by 44% of all professionals applying psychological therapies, while cognitive/behaviour therapy was preferred by only 28%, though proof of efficacy exists only for cognitive/behaviour therapy. In general, psychologists prefer behaviourally-orientated therapy, while physicians mostly propose psychodynamic therapy. One reason for the fact that the results of controlled studies have little influence on professionals treating PDA patients might be that 40% of the respondents do not accept the new classification of the anxiety disorders as introduced in 1980 by the DSM-III.

[Panic disorder and agoraphobia: what is effective?]. / Panikstörung und Agoraphobie: Was wirkt?

The present survey of controlled studies on the treatment of panic disorder and agoraphobia (PDA) reveals that treatment with tricyclic antidepressants (e.g., imipramine and clomipramine), benzodiazepines (e.g., alprazolam), serotonin reuptake inhibitors (e.g., fluvoxamine) and the monoamine oxidase inhibitor phenelzine has been proven effective. Among psychological therapies, cognitive therapy and exposure therapy in agoraphobia have been shown to be effective. There is an insufficient number of comparisons between pharmacological and psychological treatments. From the existing studies it can be assumed that none of these treatment modalities is superior to the other. The few existing follow-up studies do not suffice to prove a longer lasting effect for the psychological therapies, compared with drug therapies. Because of the low number of investigations, it cannot be clearly stated whether it is useful or harmful do treat patients with psychopharmacological drugs during psychological therapy. It is more likely that this combination is advantageous.

What treatments do patients with panic disorder and agoraphobia get?

In a retrospective study 100 patients with DSM-III-R/ICD-10 panic disorder and agoraphobia (PDA) were interviewed about the psychopharmacological, psychological and 'alternative' treatments they had received in the course of their illness. Patients gave global statements about how satisfied they were with the various treatments they had experienced. Many patients received treatments that have never been investigated under controlled conditions. The most common drug treatments, in descending order, were: 48% benzodiazepines, 42% tricyclic antidepressants, 32% herbal preparations, 29% neuroleptics, 7% selective serotonin reuptake inhibitors and 6% beta blockers. Of the drug prescriptions, 63% were according to international standards. Of the neuroleptics, two-thirds (63.3%) were prescribed by nonpsychiatric physicians, and only one-third by psychiatrists (33.3%). Tricyclic antidepressants were prescribed more often by psychiatrists (64.7%) than by non-psychiatrists (31.4%). Among psychological treatments, autogenic training (43% of the patients) and psychodynamic therapy (33%) were used far more frequently than behavioural/cognitive therapy (20%). These results confirm the underutilisation of available effective treatments for panic disorder (e.g. tricyclic antidepressants or behavioural therapy) and the overutilisation of treatments without proven efficacy (e.g. herbal preparations or autogenic training). Patients were most satisfied with treatments that have been proven effective in controlled studies. Among drug treatments, benzodiazepines, selective serotonin inhibitors and tricyclic antidepressants were favoured (mean on a 0-4 scale indicating effectiveness: 2.6, 2.6 and 2.4). Neuroleptics (1.4), beta-blockers (1.0) and herbal preparations (0.9) were not rated highly effective by the patients. Among psychological treatments, patients were more satisfied with behavioural/cognitive therapy (2.6) than with psychodynamic therapies (1.5).(ABSTRACT TRUNCATED AT 250 WORDS)