High Blood Pressure / Hypertension

Which drugs or drug regimen to use to treat hypertension

By Cardiologist on August 13th, 2011

Because the value of treating hypertension is no longer in question, the most important remaining issue is how to do it. Although lifestyle modification can be effective in some hypertensive patients, no clinical trial data exist that have shown that a nonpharmacologic regimen will reduce morbidity and mortality. Lifestyle modification, especially weight loss and sodium restriction, will reduce blood pressure modestly in many patients in the short term. Few studies have shown that even those who can adhere to a diet and achieve blood pressure reduction will maintain that benefit for more than 18-24 mo. In fact, in the only clinical trial that ever compared morbidity and mortality in those treated with lifestyle modifications alone vs those treated with lifestyle modification and pharmacologic agents — the Treatment of Mild Hypertension Study (TOMHS) — showed that the combination of drugs and lifestyle regimen reduced events statistically significantly better than successful lifestyle modification alone. Nonetheless, weight loss, physical activity, moderation of alcohol and salt intake, and attempts to reduce and cope with stress should all be strongly and unambiguously recommended to hypertensive patients. The clinician and the patient, however, should know that for the overwhelming majority of those treated to lower blood pressure and prevent cardiovascular events, pharmacologic agents will be required.

The majority of the clinical trials done recently have addressed the issue of which drugs to use. For the most part, these studies have focused on which drug to begin therapy, ignoring, perhaps, the fact that most hypertensives will require more than one agent to reach a patient’s goal.

The first major studies that compared initial therapy addressed whether regimens beginning with diuretics were as good as those beginning with β-blockers. With the exception of older hypertensive patients, in whom diuretics are clearly superior, there is no evidence that either class of agents prevents cardiovascular events better than the other.

Table Trials Addressing Which Drug or Drug Regimen to Use to Treat Hypertension

Unfortunately, there are still no definitive comparative studies of either the older class of antihypertensives appropriate for monotherapy (diuretics and β-blockers) compared to the newer classes (calcium antagonists, angiotensin-converting enzyme inhibitors, a-blockers, a/β-blockers or angiotensin receptor blockers) or of the newer classes to each other. Only the TOMHS and Veterans Administration Study of Monotherapy have attempted to do this, and neither trial was large enough to be able to define differences in event reduction or even differences in antihypertensive efficacy except in some subgroups. For example, older (>60 yr) African American men had greater blood pressure reduction with diuretics and calcium antagonists than with other classes of drugs in the Veterans Administration Study of Monotherapy. This differential blood pressure response, however, was not evident in whites or African American men under 60 yr. Small and occasionally statistically but not clinically significant differences in clinical or metabolic adverse reactions were noted, but these differences were not important enough to provide the solid evidence necessary to make firm therapeutic recommendations. There is no difference in the benefits achieved in men and women, especially in older persons or those at risk.

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