How 3 Types of Blood Pressure Medication Compare

How 3 Types of Blood Pressure Medication Compare
  • After following participants for up to 23 years, researchers found that three types of high blood pressure medications offered similar heart-related benefits, with some slight differences.
  • The medications included a calcium channel blocker, an angiotensin-converting enzyme (ACE) inhibitor and a thiazide-type diuretic.
  • Experts say treatment for high blood pressure is not a one-size-fits-all strategy. Treatment should be personalized for the patient, taking into account factors such as age and other health conditions.

Three high blood pressure medications reduced the risk of dying from heart attack, stroke or heart failure by similar amounts among people who started taking the drugs during a clinical trial decades earlier.

However, people who started with an angiotensin-converting enzyme (ACE) inhibitor during that initial trial had a slightly higher risk of dying from stroke during the long-term follow-up compared to those who took a thiazide-type diuretic.

The third type of medicine included in the initial trial was a calcium channel blocker.

The study, which was published Dec. 4 in JAMA Network OpenTrusted Source, extended the follow-up period of an earlier clinical trial.

Dr. Jim Liu, a cardiologist at The Ohio State University Wexner Medical Center in Columbus who was not part of the study, said it generally confirms the results of the initial trial, known as the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

“This current study came up with findings that were similar to the original trial,” he said, “which indicated that for the most part, the three different blood pressure medication groups had similar clinical outcomes.”

The results of the new study are unlikely to change current clinical practice, said Dr. Cheng-Han Chen, interventional cardiologist and medical director of the Structural Heart Program at MemorialCare Saddleback Medical Center in Laguna Hills, Calif.

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This is “because all three types of medications are currently considered first-line therapies for high blood pressure due to their effectiveness and safety,”.

Dr. Rigved Tadwalkar, a cardiologist at Providence Saint John’s Health Center in Santa Monica, CA, who was also not involved in the study, said the long-term analysis of the ALLHAT trial does provide valuable insights for both patients with high blood pressure and their doctors.

In particular, “this information is of importance to clinicians as they consider the most appropriate antihypertensive medication for their patients,”.

However, “while the study highlights certain differences in outcomes, it is important to note that the study does not necessarily suggest that one type of medication is universally preferable for treating high blood pressure,” Tadwalkar said.

Instead, “the choice of antihypertensive medication should continue to be tailored to the individual patient, considering factors such as age, potential for side effects and, especially, co-existing medical issues,” he said.

Blood pressure meds lower risk of early death

The initial ALLHAT studyTrusted Source was conducted from 1994 through early 2002, and followed participants for an average of about 5 years.

In that study, researchers randomly assigned 33,357 people to receive a calcium channel blocker (amlodipine), an angiotensin-converting enzyme (ACE) inhibitor (lisinopril) or a thiazide-type diuretic (chlorthalidone).

For the new study, researchers used administrative databases to follow 32,804 of these participants for up to 23 years after the start of the initial trial. This included the National Death Index (NDI), Social Security Administration and Center for Medicare & Medicaid Services (CMS) databases.

The average age of this subgroup was 69 years and 53% were men. In addition, there were 36% Black participants and 19% Hispanic participants.

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Researchers examined data to see how many people in the study died during the extended follow-up period due to cardiovascular disease, specifically heart attack, stroke or heart failure.

High blood pressure can damage the arteries and heart, and increase the riskTrusted Source of conditions such as irregular heart beats (arrhythmia), heart attack and stroke.

“The most important thing to take away from this study is that high blood pressure definitely needs to be treated in a timely fashion,” said Dr. Evelina Grayver, cardiologist and director of the Women’s Heart Program at Northwell Health’s Katz Institute for Women’s Health in New York who was not part of the study.

In the new study, the risk of dying from heart attack, stroke or heart failure was similar for all three medications during the extended follow-up period, researchers found.

“All three groups of blood pressure medications were similar at reducing most clinical outcomes,”. “This is consistent with the original trial from 20 years ago.”

However, he pointed out that there were also certain differences among the drugs, including a slightly higher risk of stroke with the ACE inhibitor compared to a diuretic. This was also seen during the initial trial.

In addition, “in diabetics, lisinopril was associated with a lower risk of mortality and coronary heart disease compared to a diuretic,” said Liu.

Tadwalkar said while there are limitations to the study’s data, clinicians will need to consider the potential risk of stroke when selecting medications for patients with high blood pressure, “especially for those who are at higher risk for stroke” due to other factors.

Personalized treatment of high blood pressure

One limitation of the new study is that researchers didn’t have data on which high blood pressure medications people were taking after the initial trial, only their cause of death.

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“Some of these patients may not be on those original medications any more,” said Liu “or they may be taking different medications.”

In addition, “their blood pressure measurements are also unknown in this extended post-trial period,” said Liu, “so there are a lot of variables at play here.”

Grayver pointed out that since the initial trial was carried out, clinical guidelines for how to treat high blood pressure (hypertension) have changed, in terms of when to treat people with medication and which types of medication to start with.

“In the past, usually the first medication was a diuretic. Now it’s either an ACE inhibitor or an ARB,”.

“So the study is a great summary of the last 23 years,” she said, including the long-term side effects of the medications, “but we have to take it with a grain of salt, because during that time our hypertension guidelines have changed tremendously.”

In terms of the slightly higher risk of stroke among participants who started taking ACE inhibitors, Grayver said while it is concerning, she would want to see more data on whether these people had another condition that increased their risk of stroke, such as carotid artery disease or atrial fibrillation (Afib).

She recommends that people talk to their physician about which high blood pressure medication is right for them, including bringing up any concerns they may have.

These conversations are especially important because “there is no cookie cutter approach to these hypertensive medications,” she said.

“Hypertension management really should be based upon personalized individualized screening, timely diagnosis and lifestyle changes, supplemented with pharmacological therapy as needed,” she said.


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