Evidence for hypertension therapies

Pharmacological therapy for hypertension has been shown to reduce mortality, and many trials use stroke as an outcome. Most patients require multiple agents for good control (ALLHAT)

ACE inhibitors (ACEi) seem to reduce stroke in patients 'not classically' hypertensive (PROGRESS) and angiotensin receptor blockers (ARB) appear superior to beta-blockers for reducing mortality, even with similar blood pressure reductions (LIFE).

Calcium channel blockers (CCB) may give better control than angiotensin receptor blockers (VALUE) though this could be off-set by a class benefit from ARBs. May be the agent of choice when adding to an ACEi in high risk patients (ACCOMPLISH)

Thiazides seem to give particularly good blood pressure control (ALLHAT) though end-points were similar for ACEi and CCB. Also, when added as a second agent to an ACEi, a calcium channel blocker may be a better choice (ACCOMPLISH)

Alpha-blockers appear less attractive and in ALLHAT this arm was stopped early for increased cardiovascular events and heart failure

Early trials of Renal denervation appeared to offer substantial blood pressure reductions in patients with resistant hypertension (Symplicity HTN-2) but blinded trials failed to show a benefit above placebo (Symplicity HTN-3)

Topic Therapy group Therapy Trial
Hypertension ACEi Benazepril ACCOMPLISH
Lisinopril ALLHAT
ARB Losartan LIFE
Valsartan VALUE
Alpha-blockers Doxazosin ALLHAT
Nitrendipine Syst-Eur
Diet DASH diet DASH
Renal denervation Renal denervation Symplicity HTN-2, Symplicity HTN-3
Thiazides Chlorthalidone SHEP, ALLHAT
Hydrochlorothiazide ACCOMPLISH