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QUESTION: In elderly people with hypertension, are newer antihypertensive drugs as effective as conventional antihypertensive drugs for reducing cardiovascular events?
312 health centres in Sweden.
6614 patients who were 70 to 84 years of age (mean age 76 y, 67% women) and had hypertension (defined as systolic blood pressure ≥180 mm Hg or diastolic blood pressure ≥105 mm Hg or both). Follow up was 100%.
Patients were allocated to 1 of 3 groups: conventional antihypertensive drugs (atenolol, 50 mg/d; metoprolol, 100 mg/d; pindolol, 5 mg/d; or fixed ratio hydrochlorothiazide, 25 mg/d, and amiloride, 2.5 mg/d) (n=2213); angiotensin converting enzyme (ACE) inhibitors (enalapril, 10 mg/d, or lisinopril, 10 mg/d) (n=2205); or calcium antagonists (felodipine, 2.5 mg/d, or isradipine, 2.5 mg/d) (n=2196).
Main outcome measures
Cardiovascular mortality. Secondary outcome measures included the combined outcome of fatal and non-fatal stroke, fatal and non-fatal myocardial infarction (MI), and other cardiovascular mortality.
Analysis was by intention to treat. The proportion of patients still receiving their randomised treatment at the last visit was 62% for the conventional drug group, 61% for the ACE inhibitor group, and 66% for the calcium antagonist group. Groups did not differ for cardiovascular mortality or the combined outcome of stroke, MI, and cardiovascular death. When results for newer drugs (calcium antagonists and ACE inhibitors) were combined, no differences were seen between newer and standard antihypertensive drugs for cardiovascular events (table). Results were similar after adjustment for age, sex, presence of diabetes, diastolic blood pressure, and smoking.
In elderly people with hypertension, newer antihypertensive drugs had similar efficacy to conventional antihypertensive drugs for reducing cardiovascular events.
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.