Commentary

The study by Hansson and colleagues confirms the similar efficacy of a wide range of antihypertensive drugs in reducing the risk for stroke, MI, or cardiovascular mortality in a large population of older patients. The patient population was similar to older patients seen in many practices, although we can infer from the Scandinavian setting of the study that few participants were of African descent. The specific choice of a drug in each category was not randomised, nor were the choices specified in the analysis. 46% of patients required ≥1 drug for blood pressure control.

Subgroup analysis showed some interesting results, with ACE inhibitors being superior to calcium antagonists in reducing the risk for congestive heart failure and MI. With >40 subgroup comparisons, these results must be interpreted cautiously, but these findings do fit our understanding of the efficacy of ACE inhibitors in congestive heart failure. The Captopril Prevention Project (a trial comparing captopril with conventional therapy in patients with hypertension) suggested that captopril was less protective against stroke than was treatment with diuretics or β blockers or both.¹ The current study reassuringly finds no differences in stroke incidence among the treatment groups.

What should physicians do with this information? First, they can be reassured that the older, generic, and usually unadvertised drugs (thiazides and β blockers) remain effective and should remain first line treatment of older patients with hypertension. Second, in those patients with proven or suspected left ventricular dysfunction, ACE inhibitors may have some advantage over calcium channel blockers in preventing congestive heart failure.