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Antihypertensives: Which Treatment Option Is Most Effective?

October 28, 2019

Angiotensin-converting enzyme (ACE) inhibitors may not be the best choice for treatment of hypertension, according to a recent study.

Although current guidelines recommend the use of any thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, dihydropyridine calcium channel blockers, and non-dihydropyridine calcium channel blockers for hypertension monotherapy, it is still unclear which of these treatment options is optimal.

The researchers developed a comprehensive framework to compare effectiveness and safety of antihypertensive drugs and outcomes from observational data from 4.9 million patients. Using the framework, they conducted a systematic, large-scale study comparing relative risk for 3 primary and 6 secondary effectiveness outcomes and 46 safety outcomes among first-line classes.

While the majority of estimates revealed no apparent effectiveness differences between drug classes, thiazide or thiazide-like diuretics demonstrated better primary effectiveness than angiotensin-converting enzyme inhibitors. Thiazide or thiazide-like diuretics were also favored in safety profiles over ACE inhibitors. Non-dihydropyridine calcium channel blockers were shown to be significantly inferior to the other classes.

“This comprehensive framework introduces a new way of doing observational health-care science at scale. The approach supports equivalence between drug classes for initiating monotherapy for hypertension—in keeping with current guidelines, with the exception of thiazide or thiazide-like diuretics superiority to angiotensin-converting enzyme inhibitors and the inferiority of non-dihydropyridine calcium channel blockers,” the authors concluded.

—Michael Potts


Suchard MA, Scheumie MJ, Krumholz HM, et al. Comprehensive comparative effectiveness and safety of first-line antihypertensive drug classes: a systematic, multinational, large-scale analysis [published online October 24, 2019]. Lancet.

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