BMJ 2001;322:1107-1109
( 5 May ) Clinical reviewEvidence
based management of hypertension
What are the elements
of good treatment for hypertension? This
is the third in a series of five articles Cynthia
D Mulrow, professor of medicine a, Michael Pignone,
assistant professor of medicine b.
a Division
of General Internal Medicine, University of Texas at San Antonio, San Antonio,
TX 78249, USA, b University of North Carolina at Chapel Hill,
Chapel Hill, NC 27599, USA Correspondence
to: M Pignone pignone@med.unc.edu
This paper summarises the
drugs available for treating patients with hypertension. It is based on a book
chapter for which more than 1500 trials and systematic reviews
were screened. The book chapter covers dyslipidaemia, diabetes, tobacco
misuse, physical inactivity, antiplatelet treatment, alcohol consumption,
and vitamin supplementation in patients with hypertension.1
Summary
points -
-
For the initial treatment
for hypertension a single agent may be appropriate or, depending on the patient's
risk factors, a combination of two or more may be needed -
-
Treatment decreases risks
of fatal and non-fatal stroke, cardiac events, and death and may improve quality
of life -
-
Thiazide diuretics seem the best first line agents for reducing rates of stroke
and death -
-
Angiotensin converting enzyme inhibitors, some blockers, and some long acting
calcium channel blockers are efficacious alternatives -
-
Short acting antagonists should be avoided as first line agents
-
-
Short acting calcium channel blockers should be avoided |
| Benefits
and harms of antihypertensive drug treatment | General
benefits Many large randomised placebo controlled trials consistently
show that antihypertensive drug treatment decreases the risk of fatal
and non-fatal stroke, cardiac events, and death in men and women with
systolic or diastolic hypertension,1-3 without adverse effect on quality of
life, which may even be improved.4 People at greater cardiovascular risk when
they start treatment, such as elderly patients with other relevant
risk factors, derive the most absolute benefit from drug treatment.
Specific
antihypertensive drugs as first line agents It is not clear whether the
benefits of specific antihypertensive drugs come from their direct
effects on raised blood pressure or whether they act by various other
multiple indirect actions. It is difficult to assess effects of particular
agents, because most large trials have used a stepped care approach
in which a second or third drug is added when the first choice does
not reduce blood pressure to target level. Evidence relating to first
line options is provided below and in the table.
Thiazide
diureticsMany large hypertension trials have compared hydrochlorothiazide,
chlorthalidone, or a combination of a thiazide and a potassium-sparing
agent (such as amiloride or triamterene) with placebo or no drug treatment.
Both low and high dosages of thiazide decrease rates of stroke and
death; but only low dosage regimens reduce coronary artery disease.5 Several different thiazides are all apparently
effective, which suggests that this is a class effect.
BlockersSystematic reviews and meta-analyses of several randomised trials compare
blockers as first line antihypertensive agents with
placebo.6-10 The data are complicated: in some trials as
many as 70% of participants also receive diuretics; in others large
numbers of participants cross over to other regimens. Nevertheless the
data suggest, but do not prove, that blockers reduce strokes but not coronary artery
disease or death. For stroke, estimates of relative risk reductions
of blockers compared
with placebo range from 0 to 0.41. 6 7 9 10 Blockers are a heterogeneous
class of agents with varying degrees of cardioselectivity and variable
intrinsic sympathomimetic activity; and it is doubtful whether the
cardiovascular benefits of different cardioselective blockers represent a class effect. Angiotensin
converting enzyme inhibitorsOne large randomised placebo controlled
trial has shown that the angiotensin converting enzyme inhibitor ramipril
reduces cardiovascular events by 22% (relative risk 0.78; 95% confidence
interval 0.70 to 0.86) and death by 16% in people at high risk.11 About half the trial participants had
hypertension; about half had a history of myocardial infarction; and
about 40% were taking blockers. Reductions in
relative risk for cardiovascular events in hypertensive patients were
equal or greater than the effect in non-hypertensive patients. A recent
overview of four randomised placebo controlled trials in patients,
most of whom had coronary heart disease, showed that angiotensin converting
enzyme inhibitors decreased strokes by 30% (15% to 43%) and coronary
heart disease by 20% (11% to 28%).12 Calcium
channel blockersOne large randomised trial compared a long acting preparation
of the dihydropyridine calcium channel blocker nisoldipine with placebo
in people aged 60 or more with isolated systolic hypertension.13 Rates of cardiovascular events with active
treatment were reduced by 31% (14% to 45%) compared with placebo. Calcium
channel blockers are a heterogeneous class of agents with various postulated
mechanisms of action and they may not have class effects in hypertensive
patients.
Aims
of treatment - Decrease
the cardiovascular risk associated with hypertension
- Decrease
the risk from coexisting cardiovascular risk factors
- Improve
quality of life and encourage a healthy lifestyle
- Choose
therapeutic agents likely to do more good than harm given each patient's social
circumstances, preferences, coexisting medical conditions, and risk factors
- Minimise the adverse effects
and inconveniences from what you prescribe
|
Agonists and blockersNo large randomised trials have compared clinical outcomes
of first line treatment with either agonists, such as clonidine,
or blockers, such as terazosin or doxazosin, with
placebo. Comparisons
of different antihypertensive agents Angiotensin converting enzyme
inhibitors, diuretics, diuretics with blockers,
and calcium channel blockersOne open long term trial in 6600 patients
aged 70 to 84 reported no differences in control of blood
pressure or in cardiovascular morbidity or mortality among people randomised
to receive conventional treatment with diuretics, alone or with blockers,
compared with calcium channel blockers (felodipine or isradipine),
and with angiotensin converting enzyme inhibitors (enalapril or lisinopril).14 A single blind long term trial in 10 985
patients aged 25-66 reported that the angiotensin converting enzyme
inhibitor captopril was not more effective than conventional treatment
(diuretics or blockers) in reducing cardiovascular morbidity or
mortality,15 but these results were inconclusive because
a flaw in the randomisation process resulted in unbalanced groups.
Two additional smaller trials compared either nisoldipine with enalapril
or amlodipine with fosinopril in hypertensive patients with type 2 diabetes.
16 17 They found that angiotensin converting enzyme inhibitors
and calcium channel blockers were equally effective in reducing blood
pressure, but calcium channel blockers were associated with a twofold
to fivefold increase in cardiovascular events compared with angiotensin
converting enzyme inhibitors. In one trial comparing captopril with
atenolol in hypertensive patients with type 2 diabetes, the groups
did not differ significantly in blood pressures or cardiovascular events.18
Blockers and diureticsOne randomised trial found that the blocker doxazosin increased the incidence
of cardiovascular events, particularly congestive heart failure, compared
with the diuretic chlorthalidone.19
Blockers and diureticsFive trials in nearly 20 000 people directly compared thiazide diuretics
with blockers as first line treatment.8 Pooled data showed a 12% difference in cardiovascular
events (relative risk 0.88 (0.78 to 1.00) thiazide v blocker) but no significant
differences in deaths (relative risk 0.97 (0.84 to 1.11)).
Systematic reviews have compared trials that used diuretics as first
line agents with those using blockers.7-10 The summary results showed no significant
differences in effect estimates between trials that tested diuretics
(compared against placebo) and trials that tested blockers (compared against placebo).
However, only diuretics showed significant reductions in coronary heart
disease events compared with placebo. Calcium
channel blockers, diuretics, and blockersOne double blind randomised trial
compared the calcium channel blocker long acting nifedipine with a
thiazide and anamiloride diuretic.20 The 6321 men and women in the study
had hypertension and at least one additional cardiovascular risk factor.
No significant differences were reported between the groups in cardiovascular
events (relative risk 110 (0.91 to 1.34), nifedipine v
diuretic). A second large open randomised trial compared diltiazem
with diuretics, alone or with blockers, in more than 10 000 Scandinavian
men and women aged 50 to 74.21 At first a short acting form of diltiazem was
used, but in the later years of the trial a long acting form was used.
After four to five years cardiovascular events were similar between
groups (relative risk 1.0 (0.87 to 1.15), diltiazem v diuretic
or blocker). Tolerability
It is not clear which specific antihypertensive agents are best
tolerated by patients. In all but one of four long term double blind
comparisons of low dose diuretics, blockers,
angiotensin converting enzyme inhibitors, and calcium channel blockers,
the diuretics and blockers tended to be more tolerable and to improve
overall quality of life more than newer drugs, 19 21-24 with the exception that diuretics showed more
serious effectsthough fewer overallthan did the long acting calcium channel blocker nifedipine.19 Serious effects were defined as "life-threatening,
disabling, or leading to hospital admission." In trials comparing thiazides
with blockers, thiazides
were associated with significantly lower rates of withdrawal due to
adverse effects (relative risk 0.69; 0.63, 0.76).8 Drugs
with minor adverse effects Adverse effects of drugs vary by drug class
and between agent within classes. For example, in the trial of 6600 people
aged 70-84 who were followed for five years, mentioned above,
26% of those receiving the calcium channel blockers felodipine or isradipine
reported ankle oedema; 30% receiving the angiotensin converting enzyme
inhibitors enalapril or lisinopril reported cough; and 9% of those
receiving diuretics with or without blockers reported cold hands and feet.14 Although such adverse effects related
to specific agents are not discussed in further detail here, the book
provides additional information about adverse effects, such as sexual
dysfunction, attributable to specific agents.1 Drugs
with major morbid or fatal adverse effects Case-control, cohort, and
randomised studies suggest that short and intermediate acting dihydropyridine
calcium channel blockers such as nifedipine and isradipine increase
cardiovascular morbidity and mortality.25 A recent overview of trials found that
calcium channel blockers significantly reduced strokes by 13% (2% to
23%) compared with diuretics and blockers but increased the incidence of coronary
heart disease by 12% (0% to 26%) and possibly heart failure by 12%
(5% to 33%).12 A large trial suggests that the agonist doxazosin increases the risk
of cardiovascular events, particularly congestive heart failure, compared
with chlorthalidone.19 One systematic review of nine case-control
and three cohort studies reported that long term use of a diuretic
about doubles the risk of renal cell carcinoma.26 Absolute risks cannot be calculated from
these studies but are likely to be low, since renal cell carcinoma
is uncommon.
| Footnotes |
Funding: None Competing
interests: MP has received funding from Pfizer Foundation for research on treating
heart failure in low literacy patients.
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BMJ 2001 This
article has been cited by other articles: - Pignone,
M., Mulrow, C. D (2001). Evidence based management of hypertension: Using cardiovascular
risk profiles to individualise hypertensive treatment. BMJ 322: 1164-1166
[Full text]
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