High blood pressure is one of the most common health problems worldwide.
It often causes no clear symptoms, but over time it can damage blood vessels and raise the risk of heart attack, stroke, heart failure, and kidney disease.
For many people, medicine is needed when lifestyle changes alone are not enough to bring blood pressure under control.
Doctors can choose from several types of blood pressure drugs.
These include ACE inhibitors, thiazide diuretics, angiotensin II receptor blockers, often called ARBs, and calcium channel blockers. All of these medicines can lower blood pressure, but researchers have long debated which one is the best choice for a person starting treatment for the first time.
A large study led by researchers at Columbia University tried to provide a clearer answer.
The team examined health records from nearly 5 million patients who had recently started medicine for high blood pressure. By comparing what happened to people taking different drugs, the researchers were able to look for differences in both effectiveness and safety.
The study found that ACE inhibitors were by far the most common starting treatment. About 48% of patients received an ACE inhibitor, while only about 17% started with a thiazide diuretic. However, the results suggested that the less commonly used thiazides may have important advantages.
People who began treatment with thiazide diuretics had about 15% fewer major heart problems than people who started with ACE inhibitors. These problems included heart attacks, strokes, and hospital treatment for heart failure. The difference is important because even a modest reduction in risk can affect many people when millions are being treated.
The researchers also found differences in side effects. ACE inhibitors were linked to a higher risk of 19 unwanted health effects compared with thiazides, including kidney problems and a persistent cough. The team estimated that about 3,100 serious heart-related events might have been avoided if the patients who received ACE inhibitors had instead started with thiazide diuretics.
Thiazide diuretics are not new medicines. They have been used for decades and help the kidneys remove extra salt and water from the body, which reduces the amount of fluid in the bloodstream and helps lower blood pressure. ACE inhibitors work differently by blocking a body process that can tighten blood vessels, allowing the vessels to relax.
The findings do not mean that ACE inhibitors are a poor choice for everyone. The best medicine can depend on a person’s age, other health conditions, kidney function, possible side effects, and other drugs they take. Some patients may have specific reasons to use an ACE inhibitor or another type of blood pressure medicine.
Still, the study suggests that doctors may want to consider thiazide diuretics more often when choosing a first treatment for uncomplicated high blood pressure. It also shows how very large collections of real-world medical records can help researchers compare treatments when traditional clinical trials do not provide all the answers.
The research was led by Dr. George Hripcsak of Columbia University and was published in the medical journal The Lancet. The findings add to evidence that an older, widely available type of medicine may deserve a larger role in the early treatment of high blood pressure.
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