Abstract
The evidence base for drug treatment of hypertension is strong. Early trials using thiazide diuretics suggested a shortfall in prevention of coronary heart disease. The superiority of newer drugs has been widely advocated but trial evidence does not support an advantage of beta-blockers, angiotensin converting enzyme inhibitors, calcium channel blockers or alpha-blockers for this outcome. Even meta-analyses have failed to clarify matters. If this issue is to be settled, bigger and better trials of longer duration in high-risk patients are needed. Meanwhile, the importance of rigorous blood pressure control using multiple drugs has been established. This should be the focus of our attention rather than agonising over differences in cause-specific outcomes that may not be generalisable to all patient populations.
Highlights
The evidence base in support of the drug treatment of hypertension is among the strongest in medicine
Prospective, randomised clinical trials in 50,000 individuals have demonstrated conclusively that pharmacological reduction of blood pressure reduces the risk of cardiovascular events and all-cause mortality [1]
Direct comparison of angiotensin converting enzyme (ACE) inhibitor and calcium channel blockers (CCB)-based therapies depended on only these two trials, between which there was significant heterogeneity and over 90% of events were reported from Swedish Trial in Old Patients with Hypertension-2 (STOP-2) [9]; this does not commentary review provide reliable evidence of a difference between ACE inhibitor and CCB-based regimens
Summary
The evidence base in support of the drug treatment of hypertension is among the strongest in medicine. In the Swedish Trial in Old Patients with Hypertension-2 (STOP-2) (ACE inhibitors or CCB versus beta-blockers or diuretics [9]) and the International Nifedipine GITS Study Intervention as a Goal in Hypertension Treatment (INSIGHT) (CCB versus diuretics [12]), withdrawal rates from randomised therapy were unacceptably high (34–39 and 33–40%, respectively). Pahor et al [18] simultaneously published a meta-analysis that suggested a highly significant 26% excess risk of coronary heart disease events with CCB-based therapy compared with other treatments. This retrospective analysis used data on 27,743 patients from nine trials, while the Trialists’ review [17] was based on 23,454 patients from six of these trials. Clinical trials provide short-term answers to longterm problems and are, in effect, surrogates for real life where treatment is often given for a lifetime
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