Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Diuretics are more efficacious than β-blockers as first-line therapy for elderly patients with hypertension

ACP J Club. 1998 Nov-Dec; 129:60. doi:10.7326/ACPJC-1998-129-3-060


Source Citation

Messerli FH, Grossman E, Goldbourt U. Are β-blockers efficacious as first-line therapy for hypertension in the elderly? A systematic review. JAMA. 1998 Jun 17;279:1903-7.


Abstract

Question

In elderly patients with hypertension, are β-blockers as efficacious as diuretics for cardiovascular morbidity and mortality and all-cause mortality?

Data sources

English-language studies were identified by searching MEDLINE (January 1966 to January 1998) using the search terms hypertension, elderly or aged or geriatric, cerebrovascular or cardiovascular disease, and morbidity or mortality and by searching CARDLINE (1986 to 1997). Bibliographies of relevant papers were also reviewed.

Study selection

Studies were selected if they were randomized trials ≥ 1 year duration, used diuretics or β-blockers as first-line agents, and reported effects on morbidity or mortality in patients ≥ 60 years of age.

Data extraction

Data were extracted on patient blood pressure response to the first-line drug, coronary heart disease (CHD), cerebrovascular events, cardiovascular mortality, and all-cause mortality.

Main results

12 studies met the selection criteria; 2 studies that focused on patients who survived a stroke were excluded from the analysis. Meta-analysis was done using intention-to-treat results from individual studies. Diuretics reduced cerebrovascular events; CHD; and stroke, cardiovascular, and all-cause mortality, whereas treatment with β-blockers reduced only cerebrovascular events (Table).

Conclusions

In elderly patients with hypertension, first-line diuretics reduced cerebrovascular events; coronary heart disease; and stroke, cardiovascular, and all-cause mortality. First-line β-blockers reduced only cerebrovascular events.

Source of funding: Not stated.

For correspondence: Dr. F.H. Messerli, Ochsner Clinic, Section on Hypertension, 1514 Jefferson Highway, New Orleans, LA 70121, USA. FAX 504-842-4104.


Table. First-line diuretics and β-blockers in elderly hypertensive patients at an approximate mean of 5-years follow-up*

Outcomes First-line diuretics β-blockers
Number of trials Pooled odds ratios (95% CI) Number of trials Pooled odds ratios (CI)
Cerebrovascular events 8 0.61 (0.51 to 0.72) 2 0.74 (0.57 to 0.98)
Coronary heart disease 8 0.74 (0.64 to 0.85) 2 1.01* (0.80 to 1.29)
Stroke mortality 7 0.67 (0.49 to 0.90) 2 0.76* (0.48 to 1.22)
Cardiovascular mortality 7 0.75 (0.64 to 0.87) 2 0.98* (0.78 to 1.23)
All-cause mortality 7 0.86 (0.77 to 0.96) 2 1.05* (0.88 to 1.25)

*Not significant.


Commentary

Thiazide or thiazide-like diuretics are inexpensive and have few contraindications or major adverse effects when used at low doses. They are especially effective in older persons with hypertension, including those with isolated systolic hypertension. In conjunction with nonpharmacologic interventions, diuretics have been shown to improve quality of life (1). Thiazides infrequently cause gout or sexual dysfunction in men, which are important but reversible consequences that demand awareness by prescriber and patient. Low-dose thiazide diuretic therapy has been endorsed by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2) as first-line monotherapy in hypertensive older persons. β-blockers, although highly effective in symptom management of ischemic disease and in secondary prevention after myocardial infarction, have a secondary role for hypertension in the elderly and are not recommended as monotherapy.

We should reflect on reasons for poor utilization of thiazide diuretics despite the class attributes. The issues are even more important in the context of an aging population with an increasing prevalence ofhypertension, a need for the simplicity of once-daily therapy with excellent 24-hour blood pressure control, and the pervasive concern of cost-effectiveness. There is a lack of pharmaceutical promotion of thiazides and a prevailing sense that thiazides are "old-fashioned." Prescriber concerns about causing hypokalemia, hyperuricemia, dyslipidemia, glucose intolerance, and cardiac arrhythmias relate to an earlier era when therapeutic choice was limited and individual drugs were commonly prescribed in excessive doses.

Altering negative attitudes to thiazides in the context of many effective, well-tolerated, newer, heavily promoted, and more expensive antihypertensive drugs will not be easy. More extensive use of low-dose diuretics surely has a place in initial therapy for elderly persons with hypertension and as part of combination treatments when low-dose diuretics do not sufficiently lower blood pressure.

S. George Carruthers, MD
University of Western OntarioLondon, Ontario, Canada


References

1. Neaton JD, Grimm RH Jr, Prineas RJ,et al. Treatment of Mild Hypertension Study. Final results. Treatment of Mild Hypertension Study Research Group. JAMA. 1993;270:713-24.

2. The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med. 1997;157:2413-46.