Diuretics Better for Blood Pressure than More Expensive Drugs

By: Jan Chait

What’s the best drug to combat high blood pressure and lower the incidence of heart failure and hospitalization for heart failure?

Good old-fashioned, inexpensive “water pills,” say researchers.

In the eight-year Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study – funded by the National Heart, Lung & Blood Institute – 33,357 subjects ages 55 and older were followed. According to the National Institutes of Health, participants initially had high blood pressure and at least one other factor that put them at risk for heart disease.

Participants were randomly assigned to take either the thiazide-type diuretic chlorthalidone, the calcium channel blocker amlodipine (Norvasc) or the ACE inhibitor lisinopril (Prinivil or Zestril).

Fatal coronary heart disease or nonfatal heart attacks – the primary outcomes studied – occurred in 2,956 participants, with no difference between the three treatment groups.

However, those who took the calcium channel blocker had a 38 percent higher risk of heart failure and a 35 percent higher risk of being hospitalized for heart failure, compared to the diuretic group.

Those who took the ACE inhibitor had higher blood pressure, a 15 percent higher risk of stroke overall (40 percent higher for African-Americans), a 19 percent higher risk of heart failure, an 11 percent higher risk of being hospitalized and a 10 percent higher risk of having to undergo bypass surgery.

Thiazide-type diuretics should be the preferred first-step drug for high blood pressure, the researchers argue, noting that these medications are “superior in preventing one or more major forms of [cardiovascular disease] and are less expensive” than the other drugs studied.

Journal of the American Medical Association, December 18, 2002

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Clinical adviser’s note: This well-conducted study found mixed results for all three classes of medications used for the treatment of high blood pressure. Only your healthcare provider can determine your special needs.

It is important to remember the added kidney protection provided by ACE inhibitors for people with diabetes. As the ALLHAT researchers note, most people with high blood pressure will require more than one type of drug to reach treatment goals. The American Diabetes Association recommends a blood pressure goal of less than 130/80 for adults with diabetes.

The thiazide-type diuretic chlorthalidone used in the ALLHAT study is not as commonly prescribed as another member of this class, hydrochlorothiazide (HCTZ). These low-cost diuretics have been prescribed in smaller doses in recent years, showing fewer side effects, such as dizziness, as a result. They can still lower blood potassium to levels that require potassium supplements. In addition, ALLHAT participants in the diuretic-treated group had slightly higher blood cholesterol and glucose levels. Slightly more participants in the diuretic-treated group went on to develop diabetes.

To review currently available medications for high blood pressure, see the comprehensive chart in our January 2003 issue (“Medications to Lower Blood Pressure,” pages 30-31).

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