Advertisement

Relative efficacy of, and some adverse reactions to, different antihypertensive regimens

  • Marvin Moser
    Correspondence
    Address for reprints: Marvin Moser, MD, Davis Avenue Medical Center, 33 Davis Avenue, White Plains, New York 10605.
    Affiliations
    From the Department of Medicine, Yale University School of Medicine, New Haven, Connecticut U.S.A.
    Search for articles by this author
      This paper is only available as a PDF. To read, Please Download here.

      Abstract

      Although it is a common belief that all antihypertensive agents are equally effective in reducing blood pressure, there is some evidence to the contrary, both in the general population and when specific patient demographics are considered. In black patients, β blockers and angiotensin-converting enzyme (ACE) inhibitors have been shown to be less effective at reducing blood pressure than the thiazide diuretics. After age 60, the percentage of responders to β blockers is less than with calcium antagonists, and a higher percentage of elderly patients also achieve normotensive blood pressure levels with diuretic therapy than with β blockers. When a thiazide diuretic is added to an ACE inhibitor, β blocker or calcium antagonist, the number of normotensive responders increases significantly. Combinations of some other agents (i.e., an ACE inhibitor plus a β blocker) may not, however, improve efficacy.
      Diuretics, β blockers and ACE inhibitors are all generally well tolerated, with a 9 to 10% incidence of subjective side effects. The use of calcium antagonists and especially the centrally acting adrenergic inhibitors may result in more frequent adverse effects.
      Data from long-term, diuretic-based clinical trials do not support the statement that diuretic therapy results in sustained elevations in lipid levels. These trials have shown cholesterol levels to be at or below baseline after long-term diuretic therapy. The use of β blockers, on the other hand, may result in long-term elevation of triglyceride levels and a slight decrease in high-density lipoprotein cholesterol. Calcium antagonists and ACE inhibitors do not affect lipid levels, and α blockers may actually lower cholesterol levels and increase high-density lipoprotein levels.
      Whereas some studies have demonstrated a link between diuretic-induced hypokalemia and increased ventricular ectopy, other studies have not. It appears prudent, however, while awaiting additional data, to prevent hypokalemia from developing in those patients at high risk for arrhythmias and heart disease. In such cases, the use of a potassium-sparing diuretic combination is probably preferable to the use of potassium supplements.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Veterans Administration Cooperative Study Group on Antihypertensive Agents
        Comparison of propranolol and hydrochlorothiazide for the initial treatment of hypertension: II. Results of long-term therapy.
        JAMA. 1982; 248: 2004-2011
        • Moser M
        • Lunn J
        Comparative effects of pindolol and hydrochlorothiazide in black hypertensive patients.
        Angiology. 1981; 32: 561-566
        • Weinberger MH
        Comparison of captopril and hydrochlorothiazide alone and in combination in mild to moderate hypertension.
        Br J Clin Pharmacol. 1982; 14: 127S-131S
        • Moser M
        Calcium entry blockers for systemic hypertension.
        Am J Cardiol. 1987; 59: 115A-121A
        • Bolzano K
        • Arriaga J
        • Bernal R
        • Bernardes H
        • Calderon JL
        • Debruyn J
        • Dienstl F
        • Drayer J
        • Goodfriend TL
        • Gross W
        • Guthrie GP
        • Holwerda N
        • Klein W
        • Krakoff L
        • Liebau H
        • Oparil S
        • Reams GP
        • Reed WG
        • Safar M
        • Schubotz R
        • Seedat YK
        • Thind GS
        • Veriava Y
        • Wollam G
        • Woods JW
        • Zusman RM
        The antihypertensive effect of lisinopril compared to atenolol in patients with mild to moderate hypertension.
        J Cardiovasc Pharmacol. 1987; 9: S43-S47
        • Moser M
        • Lunn J
        Responses to captopril and hydrochlorothiazide in black patients with hypertension.
        Clin Pharmacol Ther. 1982; 32: 307-312
        • Veterans Administration Cooperative Study Group on Antihypertensive Agents
        Comparison of propranolol and hydrochlorothiazide for the initial treatment of hypertension: I. Results of short-term titration with emphasis on racial differences in response.
        JAMA. 1982; 248: 1996-2003
        • Bühler FR
        Age and cardiovascular response adaptation: determinants of an antihypertensive treatment concept primarily based on bcta-blockers and calcium entry blockers.
        Hypertension. 1983; 5: 94-100
        • Hulley SB
        • Furberg CD
        • Gurland B
        • McDonald R
        • Perry HM
        • Schnaper HW
        • Schoenberger JA
        • Smith WM
        • Vogt TM
        Systolic Hypertension in the Elderly Program (SHEP): antihypertensive efficacy of chlorthalidone.
        Am J Cardiol. 1985; 56: 913-920
        • Amery A
        • Brixko P
        • Clement D
        • De Schaepdryver A
        • Fagard R
        • Forte J
        • Henry JF
        • Leonetti G
        • O'Malley K
        • Strasser T
        • Birkenhäger W
        • Bulpitt C
        • Deruyttere M
        • Dollery C
        • Forette F
        • Hamdy R
        • Joossens JV
        • Lund-Johansen P
        • Petrie J
        • Tuomilehto J
        • Williams B
        Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly Trial.
        Lancet. 1985; 1: 1349-1354
        • MacGregor GA
        • Markandu ND
        • Banks RA
        • Bayliss J
        • Roulston JE
        • Jones JC
        Captopril in essential hypertension; contrasting effects of adding hydrochlorothiazide or propranolol.
        Br Med J. 1982; 284: 693-696
        • Pool JL
        • Gennari J
        • Goldstein R
        • Kochar MS
        • Lewin AJ
        • Maxwell MH
        • McChesney JA
        • Mehta J
        • Nash DT
        • Nelson EB
        • Rastogi S
        • Rofman B
        • Weinberger M
        Controlled multicenter study of the antihypertensive effects of lisinopril, hydrochlorothiazide, and lisinopril plus hydrochlorothiazide in the treatment of 394 patients with mild to moderate essential hypertension.
        J Cardiovasc Pharmacol. 1987; 9: S36-S42
        • Moser M
        In defense of traditional antihypertensive therapy.
        Hypertension. 1988; 12: 324-325
        • Lasser NL
        • Grandits G
        • Caggiula AW
        • Cutler JA
        • Grimm RH
        • Kuller LH
        • Sherwin RW
        • Stamler J
        Effects of antihypertensive therapy on plasma lipids and lipoproteins in the Multiple Risk Factor Intervention Trial.
        Am J Med. 1984; 76: 52-66
        • Medical Research Council Working Party on Mild to Moderate Hypertension
        Adverse reactions to bendrofluazide and propranolol for the treatment of mild hypertension.
        Lancet. 1981; 2: 539-543
        • Hypertension Detection and Follow-up Program Cooperative Group
        Five-year findings of the Hypertension Detection and Follow-up Program: II. Mortality by race-sex and age.
        JAMA. 1979; 242: 2572-2577
        • Helgeland A
        • Hjermann I
        • Leren P
        • Enger S
        • Holme I
        High-density lipoprotein cholesterol and antihypertensive drugs: the Oslo study.
        Br Med J. 1978; 2: 403
        • Wilhelmsen L
        • Berglund G
        • Elmfeldt D
        • Fitzsimons T
        • Holzgreve H
        • Hosie J
        • Hörnkvist PE
        • Pennert K
        • Tuomilehto J
        • Wedel H
        Beta-blockers versus diuretics in hypertensive men: main results from the HAPPHY trial.
        J Hypertens. 1987; 5: 561-572
        • Moser M
        Diuretics in the management of hypertension.
        Med Clin North Am. 1987; 71: 935-946
        • Caggiula AW
        • Christakis G
        • Farrand M
        • Hulley SB
        • Johnson R
        • Lasser NL
        • Stamler J
        • Widdowson G
        The multiple risk factor intervention trial (MRFIT): IV. Intervention on blood lipids.
        Prev Med. 1981; 10: 443-475
        • Shekelle RB
        • Caggiula AW
        • Grimm Jr, RH
        Diuretic treatment of hypertension and changes in plasma lipids over 6 years in the Multiple Risk Factor Intervention Trial.
        Atherosclerosis. 1984; 12: 113-127
        • Gundersen T
        • Abrahamsen AM
        • Kjekshus J
        • Ronnevik PK
        Timolol-related reduction in mortality and reinfarction in patients ages 65–75 years surviving acute myocardial infarction.
        Circulation. 1982; 66: 1179-1184
        • Papademetriou V
        • Fletcher R
        • Khatri IM
        • Freis ED
        Thiazide therapy is not a cause of arrhythmia.
        Arch Intern Med. 1988; 148: 1272-1276
        • Madias JE
        • Madias NE
        • Gavras HP
        Nonarrhythmogenicity of diuretic-induced hypokalemia: its evidence in patients with uncomplicated hypertension.
        Arch Intern Med. 1984; 144: 2171-2176
        • Leif PD
        • Belizon I
        • Matos J
        • Bank N
        Diuretic-induced hypokalemia does not cause ventricular ectopy in uncomplicated essential hypertension (abstr).
        Kidney Int. 1984; 24: 203
        • Holland OB
        • Nixon JV
        • Kuhnert L
        Diuretic-induced ventricular ectopic activity.
        Am J Med. 1981; 70: 762-768
        • Hollifield JW
        • Slaton PE
        Thiazide diuretics, hypokalemia and cardiac arrhythmias.
        Acta Med Scand. 1981; 677 (suppl): 67-73
      1. Arch Intern Med. 1988; 148: 1023-1038