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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
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Which 2 drug regimen for hypertension
5 Feb2010
Today's BMJ has a very interesting study – Myocardial infarction and stroke associated with diuretic based two drug antihypertensive regimens: population based case-control study
Results Compared with users of diuretics plus β blockers, users of diuretics plus calcium channel blockers had an increased risk of myocardial infarction (adjusted odds ratio (OR) 1.98, 95% confidence interval 1.37 to 2.87) but not of stroke (OR 1.02, 95% CI 0.63 to 1.64). The risks of myocardial infarction and stroke in users of diuretics plus angiotensin converting enzyme inhibitors or angiotensin receptor blockers were slightly but not significantly lower than in users of diuretics plus β blockers (myocardial infarction: OR 0.76, 95% CI 0.52 to 1.11; stroke: OR 0.71, 95% CI 0.46 to 1.10).
Conclusions In patients with hypertension, diuretics plus calcium channel blockers were associated with a higher risk of myocardial infarction than other common two drug treatment regimens. A large trial of second line antihypertensive treatments in patients already on low dose diuretics is required to provide a solid basis for treatment recommendations.
While this study is not a randomized controlled trial, the results have face validity to me. I have a long dislike for calcium channel blockers compared with ACE inhibitors or beta blockers. I am always concerned that calcium channel blockers increase neurohormone levels, and I have made the assumption that we do not want higher neurohormone levels.
So I like this study. I currently teach that all two drug regimens should contain a diuretic. Recent data suggests that we should preferentially use chlorthalidone over hydrochlorothiazide. I have a long time friend who really is an expert in this field, and he recently told me that he starts patients on chlorthalidone 25 mg daily with excellent results. With that dose of chlorthalidone few patients develop hypokalemia (even fewer when used in combination with an ACE inhibitor).
Related posts:
- Rate control in a fib – not too tight
- The problem with calcium channel blockers and diuretics for hypertension
- On ACE inhibition for BP control
- 17 days at the VA – Day 2
- Taking the right medications really matters
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- In: Medical Rants
1 Response to Which 2 drug regimen for hypertension
Dominion Doc
February 10th, 2010 at 5:27 pm
A weak, weak article. I think that using a CCB-diuretic is a fairly non-sensical first choice combo, I think the question about CCB safety is pretty thoroughly answered. ACCOMPLISH serves as the most recent example.
A quote from an article from heartwire (link: http://bit.ly/bV4jKt):
And Dr Giuseppe Mancia (University of Milan-Bicocca, Monza, Italy), who is the chair of the European Society of Hypertension Educational Committee, commented to heartwire: "What does this very small paper, which is very weak, with a few hundred patients and an uncontrolled design, add to the enormous amount of evidence we have that calcium-channel blockers are as protective as other antihypertensive drugs? Absolutely nothing, and I hope the scientific community will not take any notice of this.
"The story of calcium antagonists and MI is a very old story, and this is the same group, more or less, that raised the issue in the mid-1990s based on case-control studies. Since then, a lot of water has gone under the bridge. Many, many trials and meta-analyses have disproved completely this type of evidence, which was very weak anyway," Mancia added.