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 .
Age-race subgroup compared with renin profile as predictors of blood pressure response to antihypertensive therapy. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents.
CONTEXT Renin profiling and age-race subgroup may help select single-drug therapy for stage 1 and stage 2 hypertension . OBJECTIVE To compare the plasma renin profiling and age-race subgroup methods as predictors of response to single-drug therapy in men with stage 1 and 2 hypertension as defined by the Joint National Committee on Prevention , Detection , Evaluation and Treatment of High Blood Pressure . DESIGN The Veterans Affairs Cooperative Study on Single-Drug Therapy of Hypertension , a r and omized controlled trial . SETTING Fifteen Veterans Affairs hypertension centers . PATIENTS A total of 1105 ambulatory men with entry diastolic blood pressure ( DBP ) of 95 to 109 mm Hg , of whom 1031 had valid plasma and urine sample s for renin profiling . INTERVENTIONS R and omization to 1 of 6 antihypertensive drugs : hydrochlorothiazide , atenolol , captopril , clonidine , diltiazem ( sustained release ) , or prazosin . MAIN OUTCOME MEASURE Treatment response as assessed by percentage achieving goal DBP ( < 90 mm Hg ) in response to a single drug that corresponded to patients ' renin profile vs a single drug that corresponded to patients ' age-race subgroup . RESULTS Clonidine and diltiazem had consistent response rates regardless of renin profile ( 76 % , 67 % , and 80 % for low , medium , and high renin , respectively , for clonidine and 83 % , 82 % , and 83 % , respectively , for diltiazem for patients with baseline DBP of 95 - 99 mm Hg ) . Hydrochlorothiazide and prazosin were best in low- and medium-renin profiles ;  captopril was best in medium- and high-renin profiles ( low- , medium- , and high-renin response rates were 82 % , 78 % , and 14 % , respectively , for hydrochlorothiazide ; 88 % , 67 % , and 40 % , respectively , for prazosin ; and 51 % , 83 % , and 100 % , respectively , for captopril for patients with baseline DBP of 95 - 99 mm Hg ) . Response rates for patients with baseline DBP of 95 to 99 mm Hg by age-race subgroup ranged from 70 % for clonidine to 90 % for prazosin for younger black men , from 50 % for captopril to 97 % for diltiazem for older black men , from 70 % for hydrochlorothiazide to 92 % for atenolol for younger white men , and from 84 % for hydrochlorothiazide to 95 % for diltiazem for older white men . Patients with a correct treatment for their renin profile but incorrect for age-race subgroup had a response rate of 58.7 % ; patients with an incorrect treatment for their renin profile but correct for age-race subgroup had a response rate of 63.1 % ( P = .30 ) . After controlling for DBP and interactions with treatment group , age-race subgroup ( P<.001 ) significantly predicted response to single-drug therapy , whereas renin profile was of borderline significance ( P= .05 ) . CONCLUSIONS In these men with stage 1 and stage 2 hypertension , therapeutic responses were consistent with baseline renin profile , but age-race subgroup was a better predictor of response
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 .