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Senior Health & Medicine
Inexpensive Diuretics Best to Treat High Blood
Pressure, Prevent
Heart Failure
Diuretics beat
calcium channel blockers and ACE inhibitors for treatment of high blood
pressure which often leads to heart failure
May 3, 2006 - Diuretics - the least expensive high
blood pressure medicines - are the best first step in treating high
blood pressure to prevent heart failure, according to a study reported
in Circulation: Journal of the American Heart Association. Heart failure
is the leading cause of hospitalization of senior citizens.
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“This study provides evidence for the superiority
of diuretics over calcium channel blockers and ACE inhibitors as the
base of an anti-hypertensive regimen to prevent heart failure,” said
lead author Barry R. Davis, M.D., Ph.D., professor and director of the
division of biostatistics at the University of Texas School of Public
Health in Houston.
“Achieving optimal blood pressure control is
important in heart failure prevention and control, and the type of
antihypertensive agent used plays a role.”
High blood pressure forces the heart to pump harder
to keep blood circulating. Over time, this added workload can result
in HF. In HF, the heart either doesn’t pump enough blood to meet the
needs of the body’s other organs, or gets so stiff that it has to
operate at higher pressures, resulting in tiredness, shortness of breath
and impaired kidney function.
Heart failure is a serious condition and a leading
cause of hospitalization in people age 65 and older.
“Over 90 percent of people who develop heart
failure first had high blood pressure,” said Davis, who is also director
of the Coordinating Center for Clinical Trials at the School of Public
Health. “Although not as well recognized as its effects on stroke and
heart attack, one of the benefits of treating high blood pressure is
that it helps prevent heart failure.”
In the study, researchers analyzed data from the
largest study of HBP treatment, the Antihypertensive and Lipid-Lowering
Treatment to Prevent Heart Attack Trial (ALLHAT). ALLHAT was a
randomized clinical trial of 33,357 patients, each at least 55 years
old, who had one or more risk factors for heart disease in addition to
HBP. None of the patients, average age 67, had been previously treated
for HF.
Researchers randomly selected patients in ALLHAT to
receive one of several different types of HBP medications, which were
disguised to hide their identity. The medicines were:
● Diuretic (chlorthalidone), which reduces HBP by
removing sodium and fluid in the body
●Calcium channel blocker (amlodipine), which
helps relax muscles in the blood vessels
●Angiotensin-converting enzyme (ACE) inhibitor
(lisinopril), which dilates blood vessels
Researchers dropped the alpha-blocker doxazosin
from ALLHAT early because it didn’t control HBP as well as the other
medications and resulted in increased cardiovascular disease, especially
HF, compared to the other treatments. Thus, patients on doxazosin were
not included in the ALLHAT totals in this paper.
Researchers examined patients five times during the
first year and every four months thereafter. If a patient’s blood
pressure was not controlled using the study drug, physicians could
increase the dose or prescribe a second, step-up medication. Most
people needed more than one drug to control their blood pressure.
Researchers examined the occurrence of HF serious
enough to result in hospitalization or death. “Heart failure has
serious consequences,” Davis said. “Among patients in the ALLHAT study,
there was a 5 percent death rate overall over two and a half years — but
it was five times higher in those who had been hospitalized for heart
failure.”
During the first year, patients who received the
calcium-channel blocker or ACE inhibitor were 40 percent more likely to
be hospitalized or die from HF as patients taking a diuretic. In later
years, the differences diminished, with those on the calcium channel
blocker 22 percent more likely to develop serious HF than those on
diuretics, and those on the ACE inhibitor developing HF at equivalent
rates to patients on diuretics.
“Diuretics are better than calcium channel blockers
at preventing heart failure, and better, at least in the short term,
than ACE inhibitors,” Davis said. “One reason diuretics may have an
advantage over other drugs is that they are good at decreasing the
volume that the heart has to deal with, and the other drugs don’t do
that. ACE inhibitors remodel the heart, which may have a more long-term
effect on preventing heart failure.”
Researchers said the leveling of HF rates between
the medication groups over time may be because adding step-up drugs made
their regimens more similar.
Patients who developed HF during the study were
older, weighed more, had higher systolic blood pressure, were more
likely to be male, diabetic, current smokers, and already on HBP
medication before the study began. The medication differences held
regardless of patients’ age, race, sex or whether they were diabetic.
“In addition, when we looked at heart failure that
did not require hospitalization, the differences between medications
were remarkably similar,” Davis said.
Davis said the results highlight the importance of
the recommendations of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of HBP. The committee recommends
that most patients with uncomplicated HBP be initially treated with a
diuretic, either by itself or with another medication.
“When ALLHAT began, the proportion of patients
receiving diuretics was going down. Now that decline has stopped and
the proportion is going up,” Davis said.
This study was supported by a contract with the
National Heart, Lung, and Blood Institute. The ALLHAT investigators
acknowledge contributions of study medications supplied by Pfizer, Inc (amlodipine
and doxazosin), AstraZeneca (atenolol and lisinopril), and Bristol-Myers
Squibb (pravastatin) and financial support provided by Pfizer, Inc.
Co-authors are Linda B. Piller, M.D., M.P.H.;
Jeffrey A. Cutler, M.D., M.P.H.; Curt Furberg, M.D., Ph.D.; Kay Dunn,
Ph.D.; Stanley Franklin, M.D., FACC; David Goff, M.D., Ph.D.; Frans
Leenen, M.D., Ph.D.; Syed Mohiuddin, M.D.; Vasilios Papademetriou, M.D.;
Michael Proschan, Ph.D.; Allan Ellsworth, Pharm. D.; John Golden, M.D.;
Pedro Colon, M.D., FACC; and Richard Crow, M.D.
Editor's Note: Statements and conclusions of
study authors published in the American Heart Association scientific
journals are solely those of the study authors and do not necessarily
reflect association policy or position. The American Heart Association
makes no representation or warranty as to their accuracy or reliability.
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