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Item #9
Study
Causes Debate Over ACE or Water Pills to Treat Blood-pressure
New
research on more than 6,000 patients shows that inexpensive
"water pills" may not be the best treatment for high blood
pressure, counter to the findings of a major study two months ago.
The
new research, published in last week’s New England Journal of
Medicine, has found that elderly people
with high blood pressure fared better on a type of medication known as
an ACE inhibitor, the class of drug dubbed less effective than
diuretics in a federally financed analysis of more than 42,000 people
in December.
In
last week’s report, doctors in Australia said their research shows
that an ACE inhibitor reduced the likelihood of heart attacks and
death. Heart attacks, they underscored, are a key risk factor of
hypertension. The greater benefit was entirely among men.
Enalapril
was recommended as the ACE inhibitor in the new study. The ACE
inhibitor in the U.S. research was lisinopril, which may have slightly
different pressure-lowering effects, doctors say.
As
confusing as the different findings may seem, doctors say patients
should not infer that any one class of medication is better than
another.
Dr.
Robert Phillips, chairman of medicine at Lenox Hill Hospital in New
York, said diuretics work well in some patients and ACE inhibitors in
others. Still other patients, he added, fare better with drugs such as
beta blockers, alpha blockers or calcium-channel blockers. Combining
pressure-lowering medications may produce the best response in
patients with more complicated hypertension, Phillips said.
"Even
though these studies may seem confusing to patients, they really are
not conflicting," Phillips said, adding that the U.S. and
Australian studies looked at different populations with hypertension.
Phillips
said when patients have complicating conditions, such as diabetes or
kidney disease, along with high blood pressure, ACE inhibitors may be
a reliable first choice. When hypertension is uncomplicated, he
continued, a diuretic may be a safe, inexpensive treatment.
In
an accompanying journal editorial, Dr. Edward Frohlich of the Ochsner
Clinic Foundation in New Orleans said it is shortsighted to think any
one drug can treat all hypertension patients effectively.
About
50 million Americans — one in four adults — are thought to have
high blood pressure, which increases the risk of strokes and heart
attacks.
In
the latest study of 6,083 people between age 65 and 84, half were
prescribed a diuretic and the other half received the ACE inhibitor.
The ACE inhibitor group had 11 percent fewer deaths and heart attacks
in a little over four years.
While
men in the ACE inhibitor group had 17 percent fewer deaths or
cardiovascular events than those in the diuretic group, there was no
difference among women. Men also had nearly twice the number of
"events" — 907 versus 524 — as women in the study even
though their numbers were equal.
Because
the research was not designed to determine whether men receive more
benefits from ACE inhibitors than women do, more study is needed, said
the researchers, led by Christopher Reid, head of the
cardiovascular-disease prevention unit of the Baker Heart Research
Institute in Melbourne.
The
diuretic hydrochlorothiazide and the ACE inhibitor enalapril were
recommended, but each patient's doctor chose drug and dose.
Diuretics
have been used to treat hypertension for more than a half-century.
They move water and salt out of the body, reducing the volume of blood
so the heart does not have to work as hard to push it around. ACE
inhibitors, introduced in 1981, ease blood pressure by reducing
production of a chemical that squeezes arteries.
The
diuretic used in the U.S. study costs as little as 13 cents a pill in
bulk. The ACE inhibitor can range from 35 cents per pill to $1.58.
Frohlich
lambasted a notion raised in December that the lower cost of diuretics
provided ample reason for patients to take them. He said people should
not take medications just because they're inexpensive.
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