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Diuretics Best Initial Therapy in Treating High Blood Pressure

CHICAGO, IL -- April 7, 2005 -- Thiazide-type diuretics remain the drugs of choice for initial therapy of high blood pressure in both black and nonblack patients, according to a study in the April 6 issue of JAMA.

Cardiovascular disease (CVD) has become the leading cause of illness and death worldwide, and elevated blood pressure (BP) is a leading contributor to this phenomenon, according to background information in the article.

The population of blacks with hypertension has the highest rate of illness and death from hypertension of any population group in the United States and is among the highest in the world. Death related to hypertension and the risk of end-stage renal disease (ESRD), coronary heart disease (CHD), heart failure (HF), and stroke are increased in the black compared with the white population in the United States. There is little cardiovascular outcome data for blacks with hypertension treated with the common therapies of angiotensin-converting enzyme (ACE) inhibitors or calcium channel blockers (CCBs).

Jackson T. Wright, Jr., MD, PhD, of Case Western Reserve University, Cleveland, and colleagues analyzed data from a subgroup of ALLHAT, a randomized, double-blind, clinical trial which compared high blood pressure medications. The researchers conducted this analysis to determine whether an ACE inhibitor or CCB is superior to a thiazide-type diuretic in reducing CVD incidence in racial subgroups. ALLHAT was conducted between February 1994 and March 2002 in 33,357 hypertensive U.S. and Canadian patients aged 55 years or older (35 percent black) with at least 1 other cardiovascular risk factor.

Participants took either a CCB (amlodipine), ACE inhibitor (lisinopril), or a thiazide-type diuretic (chlorthalidone). Other medications were added to achieve goal blood pressures less than 140/90 mm Hg.

The researchers found: "In both racial subgroups as in the whole cohort, neither the ACE inhibitor nor the CCB was more effective than the thiazide-type diuretic in preventing the primary outcome of myocardial infarction or fatal CHD or any other major cardiovascular or renal outcome, and diuretic-based treatment was superior to ACE inhibitors and CCBs in reducing HF incidence."

Editorial: Diuretics Are Color Blind

In an accompanying editorial, James D. Neaton, PhD, of the University of Minnesota, Minneapolis, and Lewis H. Kuller, MD, of the University of Pittsburgh, discuss the findings by Wright et al.

"After many years of research, the ALLHAT study has shown that diuretic therapy is highly efficacious in reducing the risk of CVD among both blacks and nonblacks. It is notable that with respect to the black population, ALLHAT had more events than most trials had participants. It is now time to move beyond comparisons of diuretics with other classes of BP-lowering drugs—that issue has been settled. Determining how to lower BP to more optimal levels (e.g., 120/80 mm Hg) in the most cost-effective manner and in the populations at risk is the new priority."

"More research is needed on nutritional hygienic approaches, such as those studied in [other] trials, to prevent hypertension and to supplement antihypertensive drugs. Also, it is important to continually recognize that reducing the risk of vascular disease (especially CHD) involves control of multiple risk factors to achieve maximum success. The findings of this important study have provided many ideas for the design of the next generation of trials—the children of ALLHAT," they write.


JAMA. 2005;293:1595-1608.
JAMA. 2005;293:1663-1666.


SOURCE: American Medical Association

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