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JANUARY 2003

Optimal Therapy for High Blood Pressure
by Herman Rosen, M.D.

Results of the largest study ever to determine the optimal treatment of hypertension were published December 18, 2002 in the Journal of the American Medical Association. The study, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), involved 33,357 participants 55 years or older with elevated blood pressure and at least one risk factor for coronary heart disease (CHD) such as diabetes, smoking or elevated cholesterol. Excluded were patients with known heart failure. Participants were randomly assigned to receive one of three commonly used classes of drugs: diuretics, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers (CCBs). The main outcome to be looked for was coronary heart disease or heart attack, but also looked for were stroke, heart failure and other vascular complications. Participants were followed an average of 4 years, 11 months.

The researchers from 623 clinical centers found no significant differences in the main outcome or in mortality between the three treatment groups. However, systolic blood pressure (higher number of the blood pressure reading) was lower with the diuretics than the other drugs and diastolic blood pressure (lower number of blood pressure) was lower with CCBs. There was a higher rate of heart failure with the CCB than with the diuretic. The ACE inhibitor had higher rates of stroke and heart failure than the diuretic.

This study showed that a thiazide-type diuretic (chlorthalidone) is better in preventing coronary heart disease than an ACE inhibitor (lisinopril) or a CCB (amlodipine).

Diuretics are less expensive than the other categories of drugs and should be considered for initial antihypertensive therapy. Known metabolic side effects of diuretics, such as lowered potassium levels, elevated cholesterol, and elevation of blood glucose were noted in the study but did not result in more cardiovascular disease or mortality compared with the other drugs.#

Dr. Herman Rosen is Clinical Professor of Medicine at Weill Medical College of Cornell University.

 

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