Hypertension

1995 drugs for BP part one Part two

These two parts emphasized choosing antihypertensive drugs primarily based on the results of randomized controlled trials measuring morbidity and mortality. The evidence at the present time demonstrates that low dose thiazides are effective in reducing the incidence of myocardial infarction, stroke, and overall mortality in patients with mild to severe hypertension. The amount of evidence in favor of beta blockers is less and we have little data on what dose is optimal or whether cardioselectivity and partial agonist activity are beneficial. There are no randomized controlled trials in hypertension measuring morbidity and mortality associated with ACE inhibitors and calcium channel blockers.The case control study which we referred to in Letter 8 has now been published.(6) This study shows that for the treatment of hypertension calcium channel blockers (verapamil, diltiazem, and nifedipine) are each associated with a 60% increased risk of myocardial infarction (MI) compared with thiazides and beta blockers. When the dose response relationship was evaluated, higher doses of calcium channel blockers increased the risk of MI compared with beta blockers where higher doses decreased the risk. Another interesting observation from this study is that ACE inhibitors alone were associated with an MI risk similar to diuretics and beta blockers.

Diet and hypertension

Asprin and hypertension

Which class was best at reducing mortality and morbidity? 2003

The combined major outcomes from these 2 trials plus all other RCTs comparing first-line thiazides to CCBs^4-7 are shown in the Table. Total mortality, coronary heart disease and end-stage renal disease were not different for the different classes. The most convincing morbidity difference was that CCBs increased the incidence of heart failure (events leading to death or hospitalization) over 5 years as compared to thiazides (ARI 1.7%, NNH = 61) or ACEIs (ARI 1.2%, NNH = 83). In addition, thiazides reduced the incidence of stroke as compared to ACEIs (ARR 0.5%, NNT = 200). Contrary to common opinion, in ALLHAT the thiazide was similar to the ACEI and CCB in preventing end-stage renal disease, and in a large subgroup of patients with diabetes (12,063) none of the pre-specified subgroup outcomes favored the ACEI or CCB as compared to the thiazide.¹