Diuretics look best for preventing heart failure in adults with hypertension

Hypertension causes heart failure, and antihypertensive drugs help prevent it. Some work better than others, according to a network meta-analysis of 26 trials. Diuretics looked best at preventing heart failure, followed by angiotensin converting enzyme inhibitors and angiotensin receptor blockers. Firstline treatment with β blockers or α blockers looked no more effective than placebo in these analyses, whereas calcium channel blockers worked better than placebo, definitely worse than diuretics, and probably worse than inhibitors of the renin-angiotensin system.

The authors couldn’t tell whether the differential effects on heart failure were linked to differential effects on blood pressure, but they think it unlikely. Patients with hypertension and a high risk of heart failure should probably start with diuretics or an inhibitor of the renin-angiotensin system, they write. More than 200 000 patients took part in these trials. Almost 4% (8554/223 313; 3.8%) developed heart failure during follow-up. The results were broadly comparable in men and women.

Heart failure is a neglected consequence of hypertension, and these findings should help raise its profile, says a linked comment (doi:10.1001/archinternmed.2010.414). But doctors on the front line are also trying to prevent stroke, heart attack, and cardiovascular deaths while at the same time protecting quality of life. As usual, they must juggle with medical history, likely complications, other drug treatments, and patient preferences when deciding between first line agents for high blood pressure.

BMJ 2010; 341:c6530 doi: 10.1136/bmj.c6530 (Published 16 November 2010)
Cite this as: BMJ 2010; 341:c6530

Arch Intern Med2010; doi:10.1001/archinternmed.2010.427 [PubMed Abstract]