Volume 1, Number 4, December 2000

To block the renin system or the calcium channel in hypertension – where do we stand?
Peter S Sever

Early trials of intervention in hypertensive patients failed to show that antihypertensive drugs protected against myocardial infarction (MI). Individual trials were underpowered to address this question and meta-analyses of pooled data suggested some protection (16% relative risk reduction). This represents a shortfall, since observational data predicted a 25% reduction in MI for a similar fall in blood pressure.
Comparisons of newer agents (calcium channel blockers [CCBs] and angiotensin-converting enzyme inhibitors [ACE-I]) with older agents challenged the hypothesis that drugs free of adverse metabolic sequelae would improve outcome, particularly with respect to coronary heart disease (CHD). Regrettably, these new trials were designed with unrealistic objectives, and were underpowered to establish whether CCBs or ACE-Is improve CHD outcome compared with diuretics or beta-blockers.
New meta-analyses, involving 16 trials and more than 70,000 patients, have recently been published. In trials comparing different active treatments, small differences of marginal significance were observed, and no clear discrimination between treatments can be concluded. Two large ongoing trials (The Anglo Scandinavian Cardiac Outcomes Trial [ASCOT] and Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial [ALLHAT]) and further pooled analyses will be required to define optimal treatment strategies in hypertension, for the hypertensive population as a whole and for important high-risk subgroups.

JRAAS 2000;1:325-327.

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