High blood pressure is one of the most common health problems worldwide.
It often causes no obvious symptoms, but over time it can damage blood vessels and raise the risk of heart attack, stroke, heart failure, kidney disease, and other serious conditions.
Medicines can lower this risk when lifestyle changes are not enough. Doctors have several types of blood pressure drugs to choose from, but deciding which medicine to use first is not always straightforward.
A large study led by researchers at Columbia University found that thiazide diuretics may be a better first treatment for many patients than ACE inhibitors. ACE inhibitors are widely prescribed, but the study found that thiazide drugs were linked to fewer major heart problems and fewer side effects.
The researchers examined health information from nearly 5 million people who were beginning treatment for high blood pressure. They compared several commonly used first-line drug classes, including thiazide diuretics, ACE inhibitors, angiotensin II receptor blockers, and calcium channel blockers.
ACE inhibitors were by far the most common starting treatment in the data. About 48% of patients began with an ACE inhibitor, while only about 17% started with a thiazide diuretic.
Yet the results favored thiazide diuretics when they were compared directly with ACE inhibitors. People who started with thiazides had about 15% fewer heart attacks, strokes, and cases of heart failure.
The safety results also raised questions about the widespread use of ACE inhibitors as a first treatment. The researchers found that ACE inhibitors were associated with higher rates of 19 side effects compared with thiazide diuretics.
ACE inhibitors lower blood pressure by blocking a body process that causes blood vessels to tighten. They can be very useful medicines, especially for some patients with heart or kidney conditions, but they can also cause problems such as a persistent dry cough and changes in kidney function.
Thiazide diuretics work differently. They help the kidneys remove extra salt and water from the body, reducing the amount of fluid moving through the blood vessels and helping blood pressure fall.
These medicines are not new. Thiazide diuretics have been used for decades, are generally inexpensive, and are already recommended as an option for treating high blood pressure.
The researchers estimated that about 3,100 major heart-related events might have been prevented if patients in their study who started with ACE inhibitors had instead begun treatment with a thiazide diuretic. This estimate shows how even a modest difference between treatments can have a large effect when millions of people use the medicines.
However, the findings do not mean ACE inhibitors are a poor choice for everyone. The best blood pressure medicine depends on a person’s age, other medical conditions, kidney function, possible side effects, and how well the medicine controls their blood pressure.
The study was also based on health records rather than a single large randomized clinical trial. The researchers used advanced methods to make the groups as comparable as possible, but this type of research cannot remove every possible difference between patients.
Even so, the enormous amount of real-world data gave researchers a chance to compare treatments on a scale that would be difficult to achieve in a traditional clinical trial. The findings suggest that doctors may want to consider thiazide diuretics more often when choosing a patient’s first blood pressure medicine.
The research was led by George Hripcsak and colleagues at Columbia University and was published in The Lancet. The study adds important evidence to the continuing effort to identify the safest and most effective first treatment for high blood pressure.
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