Hypertension: diuretics, beta-blockers and ACE inhibitors decrease death.

Clinical bottom line (level 1a)

  1. Patient with hypertension who are given high dose diuretics are less likely to have a stroke, than those given placebo (NNT = 102 at 5 years) .
  2. Patients given low dose diuretics are less likely to have a stroke than those given placebo (NNT = 43 at 5 years) .
  3. Patients given beta-blockers are less likely to have a stroke (NNT = 125 at 5 years) .
  4. Patients given stepped care in the Hypertension Detection and Follow-up Program Study are less likely to have a stroke than those given referred care (NNT = 96 at 5 years) .
  5. Patients given low dose diuretics are less likely to have coronary heart disease (NNT = 50 at 5 years) .
  6. High dose diuretics decrease heart failure (NNT = 415 at 5 years) .
  7. Low dose diuretics decrease heart failure (NNT = 91 at 5 years) .
  8. Beta-blockers decrease heart failure (NNT = 165 at 5 years) .
  9. High dose diuretics decrease total mortality (NNT = 109 at 5 years) .
  10. Stepped care decreases total mortality (NNT = 147 at 5 years) .
  11. ACE inhibitors decrease mortality.
  12. High dose nifedipine increases mortality.
Psaty et al: Journal of the American Medical Association 1997; 277 (9): 739-745
Expires March 2003

The study

Systematic review of Randomised placebo controlled trials of
  • Patients: hypertension
  • Intervention: antihypertensives- beta-blockers, diuretics, calcium channel blockers and angiotensin converting enzyme (ACE) inhibitors compared with placebo
  • Outcome: major events- stroke, coronary heart disease, congestive heart failure and mortality



Articles found in English and non-English using MEDLINE, 1980 to 1995 (search terms: (cerebrovascular disease or heart diseases) and ( randomized controlled trial and [antihypertensive agents (therapeutic use) or hypertension (drug therapy)]. ) and Searching previous meta-analyses.

Selection criteria: Trials had to be at least one year long.
Appraisal criteria: detailed in text
Articles excluded if: Multiple risk factor intervention trials, trials using first-line agents other than those noted above and trials comparing beta-blockers with diuretics.

Eighteen trials involving 48,220 patients followed for an average of five years were included.

The evidence

Outcome Time to outcome CER RR
(95% CI)		 NNT
(95% CI)
stroke with high dose diuretics 5 years 232/12075
(1.92%)		 0.49
(0.39 to 0.62) 		102
(85 to 137)
stroke with low dose diuretics 5 years 347/5116
(6.78%)		 0.66
(0.55 to 0.78) 		43
(33 to 67)
stroke with beta-blockers 5 years 335/12147
(2.76%)		 0.71
(0.59 to 0.86) 		125
(88 to 259)
stroke with Hypertension Detection and Follow-up Program Study 5 years 158/5455
(2.90%)		 0.64
(0.50 to 0.82) 		96
(69 to 192)
coronary heart disease with low dose diuretics 5 years 363/5116
(7.10%)		 0.72
(0.61 to 0.85) 		50
(36 to 94)
heart failure with high dose diuretics 5 years 35/12075
(0.29%)		 0.17
(0.07 to 0.41) 		415
(371 to 584)
heart failure with low dose diuretics 5 years 134/5116
(2.62%)		 0.58
(0.44 to 0.76) 		91
(68 to 159)
heart failure with beta-blockers 5 years 175/12147
(1.44%)		 0.58
(0.40 to 0.84) 		165
(116 to 434)
total mortality with high dose diuretics 5 years 390/5116
(7.62%)		 0.88
(0.75 to 1.03) 		109
(52 to 437)
total mortality with Hypertension Detection and Follow-up Program Study 5 years 240/5455
(4.40%)		 0.83
(0.72 to 0.95) 		147
(89 to 500)
mortality with ACE inhibitors 5 years /
(%)		 0.77
(0.67 to 0.88)
mortality with doses of nifedipine 80 mg or more 5 years /
(%)		 2.64
(1.42 to 4.92)

Comments

  1. Results for calcium channel blockers came from six trials and the results for ACE inhibitors came from another meta-analysis.
  2. ACE inhibitors ma be most useful in patents with co-existing congestive cardiac failure

Citation

  1. Psaty BM, Smith NL, Siscovick DS, et al: Health outcomes associated with antihypertensive therapies used as first-line agents: A systematic review and meta-analysis. Journal of the American Medical Association 1997; 277 (9): 739-745
Contributor: Clare Wotton and Musab Hayatli, January 2000
Reviewer: Santiago Alvarez Montero

Clinical Question.
Patient hypertension
Intervention or Exposure antihypertensive therapies, ACE inhibitors, calcium channel blockers, diuretics, beta blockers
Comparison placebo
Outcome major events