Antihypertensive Efficacy of Hydrochlorothiazide as Evaluated by Ambulatory Blood Pressure Monitoring A Meta-Analysis of Randomized Trials.
J Am Coll Cardiol. 2011 Feb 1;57(5):590-600
Authors: Messerli FH, Makani H, Benjo A, Romero J, Alviar C, Bangalore S
OBJECTIVES: The purpose of this study was to evaluate the antihypertensive efficacy of hydrochlorothiazide (HCTZ) by ambulatory blood pressure (BP) monitoring. BACKGROUND: HCTZ is the most commonly prescribed antihypertensive drug worldwide. More than 97% of all HCTZ prescriptions are for 12.5 to 25 mg per day. The antihypertensive efficacy of HCTZ by ambulatory BP monitoring is less well defined. METHODS: A systematic review was made using Medline, Cochrane, and Embase for all the randomized trials that assessed 24-h BP with HCTZ in comparison with other antihypertensive drugs. RESULTS: Fourteen studies of HCTZ dose 12.5 to 25 mg with 1,234 patients and 5 studies of HCTZ dose 50 mg with 229 patients fulfilled the inclusion criteria. The decrease in 24-h BP with HCTZ dose 12.5 to 25 mg was systolic 6.5 mm Hg (95% confidence interval: 5.3 to 7.7 mm Hg) and diastolic 4.5 mm Hg (95% confidence interval: 3.1 to 6.0 mm Hg) and was inferior compared with the 24-h BP reduction of angiotensin-converting enzyme inhibitors (mean BP reduction 12.9/7.7 mm Hg; p < 0.003), angiotensin-receptor blockers (mean BP reduction 13.3/7.8 mm Hg; p < 0.001), beta-blockers (mean BP reduction 11.2/8.5 mm Hg; p < 0.00001), and calcium antagonists (mean BP reduction 11.0/8.1 mm Hg; p < 0.05). There was no significant difference in both systolic (p = 0.30) and diastolic (p = 0.15) 24-h BP reduction between HCTZ 12.5 mg (5.7/3.3 mm Hg) and HCTZ 25 mg (7.6/5.4 mm Hg). However, with HCTZ 50 mg, the reduction in 24-h BP was significantly higher (12.0/5.4 mm Hg) and was comparable to that of other agents. CONCLUSIONS: The antihypertensive efficacy of HCTZ in its daily dose of 12.5 to 25 mg as measured in head-to-head studies by ambulatory BP measurement is consistently inferior to that of all other drug classes. Because outcome data at this dose are lacking, HCTZ is an inappropriate first-line drug for the treatment of hypertension.
PMID: 21272751 [PubMed - as supplied by publisher]
What’s left for high blood pressure? This meta-analysis suggests we should no longer consider hydrochlorothiazide as a first-line agent for hypertension, contradicting the recommendations of JNC-7 (http://www.ncbi.nlm.nih.gov/pubmed/12748199). Recently, we were also told to avoid non-vasodilating beta-blockers (http://beckerinfo.net/JClub/2010/12/04/beta-blockers-in-hypertension/) ; a class also highly favored in JNC-7. The literature is now trending towards fixed-dose combinations as initial therapy in some populations (see, for example, http://beckerinfo.net/JClub/2010/11/17/2010-guidelines-of-the-taiwan-society-of-cardiology-for-the-management-of-hypertension/). It will be interesting to see the impact on next year’s JNC-8.