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First‐line drugs for hypertension

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Abstract

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Background

Sustained elevated blood pressure, unresponsive to lifestyle measures, leads to a critically important clinical question: What class of drug to use first‐line? This review answers that question.

Objectives

Primary objective: To quantify the benefits and harms of the major first‐line anti‐hypertensive drug classes: thiazides, beta‐blockers, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, alpha‐blockers, and angiotensin II receptor blockers (ARB).

Search methods

Electronic search of MEDLINE (Jan. 1966‐June 2008), EMBASE, CINAHL, the Cochrane clinical trial register, using standard search strategy of the hypertension review group with additional terms.

Selection criteria

Randomized trials of at least one year duration comparing one of 6 major drug classes with a placebo or no treatment. More than 70% of people must have BP >140/90 mmHg at baseline.

Data collection and analysis

The outcomes assessed were mortality, stroke, coronary heart disease (CHD), cardiovascular events (CVS), decrease in systolic and diastolic blood pressure, and withdrawals due to adverse drug effects. Risk ratio (RR) and a fixed effects model were used to combine outcomes across trials.

Main results

Of 57 trials identified, 24 trials with 28 arms, including 58,040 patients met the inclusion criteria.
Thiazides (19 RCTs) reduced mortality (RR 0.89, 95% CI 0.83, 0.96), stroke (RR 0.63, 95% CI 0.57, 0.71), CHD (RR 0.84, 95% CI 0.75, 0.95) and CVS (RR 0.70, 95% CI 0.66, 0.76). Low‐dose thiazides (8 RCTs) reduced CHD (RR 0.72, 95% CI 0.61, 0.84), but high‐dose thiazides (11 RCTs) did not (RR 1.01, 95% CI 0.85, 1.20).
Beta‐blockers (5 RCTs) reduced stroke (RR 0.83, 95% CI 0.72, 0.97) and CVS (RR 0.89, 95% CI 0.81, 0.98) but not CHD (RR 0.90, 95% CI 0.78, 1.03) or mortality (RR 0.96, 95% CI 0.86, 1.07).
ACE inhibitors (3 RCTs) reduced mortality (RR 0.83, 95% CI 0.72‐0.95), stroke (RR 0.65, 95% CI 0.52‐0.82), CHD (RR 0.81, 95% CI 0.70‐0.94) and CVS (RR 0.76, 95% CI 0.67‐0.85).
Calcium‐channel blocker (1 RCT) reduced stroke (RR 0.58, 95% CI 0.41, 0.84) and CVS (RR 0.71, 95% CI 0.57, 0.87) but not CHD (RR 0.77 95% CI 0.55, 1.09) or mortality (RR 0.86 95% CI 0.68, 1.09). No RCTs were found for ARBs or alpha‐blockers.

Authors' conclusions

First‐line low‐dose thiazides reduce all morbidity and mortality outcomes. First‐line ACE inhibitors and calcium channel blockers may be similarly effective but the evidence is less robust. First‐line high‐dose thiazides and first‐line beta‐blockers are inferior to first‐line low‐dose thiazides.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

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Thiazides best first choice for hypertension

One of the most important decisions in treating people with elevated blood pressure is what drug class is used first. This decision has enormous consequences in terms of health outcomes and cost. In this review health outcomes resulting from 4 drug classes are summarized. Most of the evidence demonstrated that first‐line low‐dose thiazides reduce mortality and morbidity (stroke, heart attack and heart failure). No other drug class improved health outcomes better than low‐dose thiazides, and beta‐blockers and high‐dose thiazides were inferior. Low‐dose thiazides should be the first choice drug in most patients with elevated blood pressure. Fortunately, thiazides are also very inexpensive.