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Pharmacologic Treatment of Arterial Hypertension: Facts and Scientific Evidences Versus Suppositions and Missconceptions |
V.Barbakadze,
L.Koblianidze
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In
the first half of the 20th century there existed a statement
that arterial hypertension was an essential adaptive reaction - a
compensatory mechanism which provides adequate blood flow to vital organs
especially in elderly people. Since
the 60-s clinical trials based on thiazide diuretics and b-blockers
as the first step of antihypertensive therapy have proven efficiency of
antihypertensive treatment for prevention complications and prolongation
survival. At
the end of December, 2002 the
results of the largest study
ever carried out in hypertension history – ALLHAT ( The Antihypertensive
and Lipid-Lowering Treatment to Prevent Heart Attack Trial) were
published. The objective of
this study was to determine whether treatment with a calcium channel
blocker (CCB), a-blocker
or an angiotensin-converting enzyme inhibitor lowers the incidence of
coronary heart disease (CHD) or other cardiovascular disease (CVD) events
when compared to treatment with a diuretic. It was a randomized,
double-blind, active-controlled clinical trial conducted from February
1994 through March 2002. A total of 42 424 participants aged 55 years or
older with hypertension and at least 1 other CHD risk factor from 623
North American centers were enrolled in the study. Mean follow-up was 4.9
years.All-cause mortality did not differ between the groups. For
amlodipine vs chlorthalidone secondary outcomes (all-cause mortality,
stroke, combined CHD and combined CVD) were similar except for a higher
6-year rate of Heart
failure (HF) with
amlodipine. For lisinopril vs chlorthalidone, lisinopril had higher 6-year
rates of combined CVD, stroke and HF. The
results of ALLHAT indicate that thiazide-type diuretics are superior in
preventing 1 or more major forms of CVD and are less expensive. They
should be considered first for pharmacologic therapy in patients with
arterial hypertension (14). The
new US guidelines for the prevention and treatment of hypertension have
been issued by the National Heart, Lung, and Blood Institute (NHLBI) of
the National Institutes of Health (39). The main difference in JNC 7
compared with JNC 6 is the new classification of hypertension itself. The
categories of blood pressure have been reduced to 3: normal,
prehypertension, and hypertension. JNC 7 identifies high SBP, a more
important risk factor than DBP in patients aged > 50 years, as having
worse control rates. Lifestyle changes, as for prehypertensive individuals, are recommended for all hypertensive patients. For the pharmacologic treatment of hypertension, the report emphasizes the importance of ACE inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, CCB, and thiazide-type diuretics, noting that they have all been shown in clinical trials to reduce cardiovascular complications. JNC 7 makes the point that thiazide diuretics have been the basis of antihypertensive therapy in most outcome trials and says that in these trials, including ALLHAT, diuretics have been "virtually unsurpassed" in preventing the cardiovascular complications of hypertension. In stage 1 uncomplicated hypertension, thiazide-type diuretics are recommended in most patients, although ACE inhibitors, ARBs, beta-blockers, or CCBs -- or their combination -- may be considered. In patients with stage 2 hypertension, treatment may be initiated with 2 drugs, one of which, as JNC 7 recommends, should be a diuretic. |
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