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Which Antihypertensive Best Prevents HF in Patients with High BP?

ALLHAT data bolster the case for diuretic-based therapy.

Heart failure (HF) is a serious potential consequence of long-standing hypertension. Some antihypertensive agents have been shown to reduce the risk for HF. To compare how well different antihypertensive drug classes prevent HF, investigators analyzed data from 33,357 hypertensive subjects (age 55) in the randomized ALLHAT trial who had received the diuretic chlorthalidone, the ACE inhibitor lisinopril, or the calcium-channel blocker amlodipine (Journal Watch Cardiology Jan 31 2003). At baseline, these patients also had one other cardiovascular risk factor, but no HF or LV systolic dysfunction.

During a mean follow-up of 5 years, 5% of subjects developed HF. In the first year, the relative risk for HF was significantly greater with amlodipine (RR, 2.24) and lisinopril (RR, 2.08) than with chlorthalidone. Beyond the first year, amlodipine conferred significantly greater risk for HF compared with chlorthalidone (RR, 1.24) or lisinopril (RR, 1.28). Amlodipine's longer-term risks for HF remained statistically significant after adjustment for several factors, including the blood-pressure level achieved and more-stringent statistical criteria that accounted for multiple comparisons.

Comment: In ALLHAT, the risk for new-onset HF was significantly lower when the long-term antihypertensive agent was a diuretic or an ACE inhibitor rather than a calcium-channel blocker. As the editorialists note, many patients need multiple antihypertensive drugs to reach BP targets, rendering moot the search for a single best agent. Furthermore, HF is one of many complications that treatment is intended to prevent. Nevertheless, this study bolsters the case for making a relatively inexpensive diuretic a component of therapy for the majority of patients with hypertension.

— Frederick A. Masoudi, MD, MSPH

Published in Journal Watch Cardiology December 27, 2006

Citation(s):

Davis BR et al. Role of diuretics in the prevention of heart failure: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Circulation 2006 May 9; 113:2201-10.

Yusuf S. Preventing vascular events due to elevated blood pressure. Circulation 2006 May 9; 113:2166-8.