Diuretics Best Initial Therapy For Both Black And Nonblack Patients In
Treating High Blood Pressure

CHICAGO - Thiazide-type diuretics remain the drugs of choice for
initial therapy of high blood pressure in both black and nonblack
patients, according to a study in the April 6 issue of JAMA.

Cardiovascular disease (CVD) has become the leading cause of illness
and death worldwide, and elevated blood pressure (BP) is a leading
contributor to this phenomenon, according to background information in
the article. The population of blacks with hypertension has the highest
rate of illness and death from hypertension of any population group in
the United States and is among the highest in the world. Death related
to hypertension and the risk of end-stage renal disease (ESRD),
coronary heart disease (CHD), heart failure (HF), and stroke are
increased in the black compared with the white population in the United
States.  There is little cardiovascular outcome data for blacks with
hypertension treated with the common therapies of
angiotensin-converting enzyme (ACE) inhibitors or calcium channel
blockers (CCBs).

Jackson T. Wright, Jr., M.D., Ph.D., of Case Western Reserve
University, Cleveland, and colleagues analyzed data from a subgroup of
ALLHAT, a randomized, double-blind, clinical trial which compared high
blood pressure medications.  The researchers conducted this analysis to
determine whether an ACE inhibitor or CCB is superior to a
thiazide-type diuretic in reducing CVD incidence in racial subgroups.
ALLHAT was conducted between February 1994 and March 2002 in 33,357
hypertensive U.S. and Canadian patients aged 55 years or older (35
percent black) with at least 1 other cardiovascular risk factor.

Participants took either a CCB (amlodipine), ACE inhibitor
(lisinopril), or a thiazide-type diuretic (chlorthalidone). Other
medications were added to achieve goal blood pressures less than 140/90
mm Hg.

The researchers found: "In both racial subgroups as in the whole
cohort, neither the ACE inhibitor nor the CCB was more effective than
the thiazide-type diuretic in preventing the primary outcome of
myocardial infarction or fatal CHD or any other major cardiovascular or
renal outcome, and diuretic-based treatment was superior to ACE
inhibitors and CCBs in reducing HF incidence."

(JAMA. 2005;293:1595-1608.

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Editorial: Diuretics Are Color Blind

In an accompanying editorial, James D. Neaton, Ph.D., of the University
of Minnesota, Minneapolis, and Lewis H. Kuller, M.D., of the University
of Pittsburgh, discuss the findings by Wright et al.

"After many years of research, the ALLHAT study has shown that diuretic
therapy is highly efficacious in reducing the risk of CVD among both
blacks and nonblacks. It is notable that with respect to the black
population, ALLHAT had more events than most trials had participants.
It is now time to move beyond comparisons of diuretics with other
classes of BP-lowering drugs-that issue has been settled. Determining
how to lower BP to more optimal levels (e.g., 120/80 mm Hg) in the most
cost-effective manner and in the populations at risk is the new
priority."

"More research is needed on nutritional hygienic approaches, such as
those studied in [other] trials, to prevent hypertension and to
supplement antihypertensive drugs. Also, it is important to continually
recognize that reducing the risk of vascular disease (especially CHD)
involves control of multiple risk factors to achieve maximum success.
The findings of this important study have provided many ideas for the
design of the next generation of trials-the children of ALLHAT," they
write.

(JAMA. 2005;293:1663-1666.