New research questions whether a common drug is the best
approach
by Robin Westen, AARP, December 31, 2019
About six months ago, during my annual
checkup, I was surprised to learn that my blood pressure numbers were on the
rise and creeping into the danger zone.
I shouldn't have been. At age 69, I'm a prime
candidate for high blood
pressure (HBP). In fact, by the time we reach 65 years of age, more
than three-quarters of U.S. adults have HBP, a condition in which blood pushes
too forcefully against arteries, according to the National Center for Health
Statistics. If left untreated, it can lead to serious coronary damage or
stroke.
As a new member of the hypertension club, I
was referred to a cardiologist and, a week later, prescribed an ACE inhibitor,
a drug considered the first-line treatment for high blood pressure and taken by
millions of Americans.
I took my pill every day and, because it
lowered my blood pressure, I never gave it a second thought. That is, until I
read about an impressive new study concluding that ACE inhibitors are not the
best option to try initially when attempting to bring blood pressure under
control. So now what?
The choices
The study, published in October in the medical journal the Lancet,
is a whopper in its size and scope. Researchers gathered data from four
countries (Germany, Japan, South Korea and the United States) on nearly 5
million patients who had started treatment for hypertension. The purpose of the
research was to compare the effectiveness and safety of the first-line
treatments recommended by both the American Heart Association and the American
College of Cardiology.
The medications included in the study were:
·
Vasodilators,
angiotensin-converting enzyme (ACE) inhibitors and angiotensin; they all work in a similar way by
relaxing constricted blood vessels.
·
Thiazide
diuretics, which lower
blood pressure by helping the body eliminate extra water and sodium.
·
Beta-blockers, a class of drugs that reduce heart rate
and the output of blood, thus reducing blood pressure.
Why diuretics might be best
After analyzing the health records of these
millions of hypertensive patients, the researchers discovered that patients who
were prescribed thiazide diuretics had 15 percent fewer heart attacks, strokes
and hospitalizations as a result of heart failure than those patients who
started their HBP treatment with ACE inhibitors. The mega study also reported
that ACE inhibitors caused more unwanted and frequent side effects, including
cough, diarrhea, rash and angioedema (swelling of tissues around the face, lips
and tongue), as well as kidney failure. The most common side effect of diuretic
medication, on the other hand, was low potassium or low sodium, which can be
remedied easily with supplements.
Take Your
Medication at Bedtime
No matter what HBP drug you're on, take it at bedtime. In a
study of almost 20,000 patients, folks who took their drugs at night cut their
overall heart risk nearly in half compared with people who took their pills in
the morning.
"If the 2.4 million patients in the study
who were taking ACE inhibitors had been prescribed thiazide diuretics instead,
3,100 or more cardiovascular events [heart attacks or other heart-damaging
emergencies] could have been avoided,” reports the study's coauthor, George
Hripcsak, chair of biomedical informatics at Columbia University's College of
Physicians and Surgeons in New York City.
ACE inhibitors, traditionally the first-line
hypertension drugs, were prescribed for 48 percent of the study's patients,
compared with thiazide diuretics, prescribed for 17 percent of patients. (The
different types of beta-blockers were found to be the least effective, as well
as the least frequently prescribed.)
But despite ACE inhibitors’ popularity among
physicians, Hripcsak stands firmly by the results of his data. “We've been
working for 10 years, building large databases, asking questions and getting
answers in a reliable way,” he says.
The method the researchers used is known as
Large-Scale Evidence Generation and Evaluation across a Network of Databases,
or LEGEND. It uses advanced analytics to account for numerous variables while
also minimizing mistakes. “I believe this is the best observational study on
this subject that we've ever had,” Hripcsak says. He points out that the huge
amount of data pointed to patterns that would have taken 22,000 typical studies
to find.
Factors to consider in managing high blood pressure
Not everyone is convinced that diuretics
should be the first line of treatment. “What's interesting about the study is
the way the researchers looked at the data of such a large number of patients,”
says Luke Laffin, a preventive cardiologist affiliated with the Cleveland
Clinic. But, Laffin says, the study didn't look at how people of different
races respond to different medications. For example, previous data shows that
African Americans may respond best to a diuretic when it's combined with an ACE
inhibitor. “What really determines your outcome is how well your blood pressure
is lowered by a particular medication. The data surveyed didn't look at how
much the blood pressure numbers went down; it only reported the patients’
starting numbers,” Laffin says.
Talk with your doctor about your medications
It's always a good idea to have a conversation
with your doctor if you have questions about your medication. I did that and
was reassured by my cardiologist that as long as the ACE inhibitor was keeping
my blood pressure lowered and I wasn't experiencing any side effects, there was
no reason to change my treatment. Even Hripcsak agrees: “ACE inhibitors are
good drugs and produce more benefits than harm. But they just might not be the
best choice."
Robin Westen is an Emmy-winning and National
Magazine Award–nominated author and journalist.
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