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(Circulation. 2000;101:e209.)
© 2000 American Heart Association, Inc.

Circulation Electronic Pages

Trends in Antihypertensive Drug Treatment

Lionel H. Opie

Cape Heart Center Cape Town, South Africa

	Introduction

 
To the Editor:

It is disappointing to read once again that "ß-blockers and thiazide diuretics are the only antihypertensive agents that have been shown to reduce cardiovascular mortality."¹ In these days of evidence-based medicine, we must ask: where is the evidence for this statement? The basic data referenced by Wang et al¹ are those of the meta-analysis of Psaty et al,² which are also shown in the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Yet, Figure 6 in the report shows very clearly that cardiovascular and total mortality are not reduced by ß-blockade; the confidence intervals in both cases clearly overlap unity and are therefore not significant. Likewise, coronary heart disease is also not reduced by ß-blockade, although stroke and congestive heart failure are. In contrast, all these end points are clearly reduced by low-dose diuretics. In another meta-analysis that focused on the elderly, diuretics but not ß-blockers reduced cardiovascular mortality.³ It is difficult to understand why Wang et al included the Metoprolol Atherosclerosis Prevention in Hypertension (MAPHY) study as evidence for the benefits of ß-blockade. This was an open-label, unblinded study without placebo control.

A further implication of the article by Wang et al is that calcium-channel blockers do not reduce cardiovascular mortality. However, in the Systolic Hypertension in Elderly in Europe (SYST-EUR) study of elderly patients with systolic hypertension, the dihydropyridine nitrendipine was particularity efficacious in diabetic patients, in whom cardiovascular mortality was strikingly reduced (odds ratio, 0.24; . . . [Full Text of this Article]

Thomas J. Wang, MD; John C. Ausiello, BA; Randall S. Stafford, MD, PhD

Institute for Health Policy, Massachusetts General Hospital, Boston, Mass