Optimal Therapy for High
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
Dr. Herman Rosen is Clinical Professor of Medicine at Weill
Medical College of Cornell University.