We found predominantly moderate quality evidence that all-cause mortality is similar when first-line RAS inhibitors are compared to other first-line antihypertensive agents .
First-line thiazides caused less HF and stroke than first-line RAS inhibitors .
Compared with first-line CCBs , first-line RAS inhibitors reduced HF but increased stroke .
The magnitude of the reduction in HF exceeded the increase in stroke .
The small differences in effect on blood pressure between the different classes of drugs did not correlate with the differences in the primary outcomes
BACKGROUND Renin-angiotensin system ( RAS ) inhibitors are widely prescribed for treatment of hypertension , especially for diabetic patients on the basis of postulated advantages for the reduction of diabetic nephropathy and cardiovascular morbidity and mortality .
Despite widespread use of angiotensin converting enzyme ( ACE ) inhibitors and angiotensin receptor blockers ( ARBs ) for hypertension in both diabetic and non-diabetic patients , the efficacy and safety of RAS inhibitors compared to other antihypertensive drug classes remains unclear .
OBJECTIVES To evaluate the benefits and harms of first-line RAS inhibitors compared to other first-line antihypertensive drugs in patients with hypertension .
Role of Diuretics in the Prevention of Heart Failure: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
Background — Hypertension is a major cause of heart failure ( HF ) and is antecedent in 91 % of cases . The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ( ALLHAT ) stipulated assessment of the relative effect of chlorthalidone , lisinopril , and amlodipine in preventing HF . Methods and Results — ALLHAT was a double-blind , r and omized , clinical trial in 33 357 high-risk hypertensive patients aged ≥55 years . Hospitalized/fatal HF outcomes were examined with proportional-hazards models . Relative risks ( 95 % confidence intervals ; P values ) of amlodipine or lisinopril versus chlorthalidone were 1.35 ( 1.21 to 1.50 ; < 0.001 ) and 1.11 ( 0.99 to 1.24 ; 0.09 ) . The proportional hazards assumption of constant relative risk over time was not valid . A more appropriate model showed relative risks of amlodipine or lisinopril versus chlorthalidone during year 1 were 2.22 ( 1.69 to 2.91 ; < 0.001 ) and 2.08 ( 1.58 to 2.74 ; < 0.001 ) , and after year 1 , 1.22 ( 1.08 to 1.38 ; P=0.001 ) and 0.96 ( 0.85 to 1.10 ; 0.58 ) . There was no significant interaction between prior medication use and treatment . Baseline blood pressures were equivalent ( 146/84 mm Hg ) and at year 1 were 137/79 , 139/79 , and 140/80 mm Hg in those given chlorthalidone , amlodipine , and lisinopril . At 1 year , use of added open-label atenolol , diuretics , angiotensin-converting enzyme inhibitors , and calcium channel blockers in the treatment groups was similar . Conclusions — HF risk decreased with chlorthalidone versus amlodipine or lisinopril use during year 1 . Subsequently , risk for those individuals taking chlorthalidone versus amlodipine remained decreased but less so , whereas it was equivalent to those given lisinopril . Prior medication use , follow-up blood pressures , and concomitant medications are unlikely to explain most of the HF differences . Diuretics are superior to calcium channel blockers and , at least in the short term , angiotensin-converting enzyme inhibitors in preventing HF in hypertensive individuals
We found predominantly moderate quality evidence that all-cause mortality is similar when first-line RAS inhibitors are compared to other first-line antihypertensive agents .
First-line thiazides caused less HF and stroke than first-line RAS inhibitors .
Compared with first-line CCBs , first-line RAS inhibitors reduced HF but increased stroke .
The magnitude of the reduction in HF exceeded the increase in stroke .
The small differences in effect on blood pressure between the different classes of drugs did not correlate with the differences in the primary outcomes
BACKGROUND Renin-angiotensin system ( RAS ) inhibitors are widely prescribed for treatment of hypertension , especially for diabetic patients on the basis of postulated advantages for the reduction of diabetic nephropathy and cardiovascular morbidity and mortality .
Despite widespread use of angiotensin converting enzyme ( ACE ) inhibitors and angiotensin receptor blockers ( ARBs ) for hypertension in both diabetic and non-diabetic patients , the efficacy and safety of RAS inhibitors compared to other antihypertensive drug classes remains unclear .
OBJECTIVES To evaluate the benefits and harms of first-line RAS inhibitors compared to other first-line antihypertensive drugs in patients with hypertension .