Blood pressure control with ACE inhibitor or diuretic?

An Australian study published in The New England Journal of Medicine has challenged the American ALLHAT trial that showed diuretics were superior to ACE (angiotensin-converting enzyme) inhibitors and calcium channel blockers in controlling blood pressure. The Australian study included 6,083 people who were mostly white. Blood pressure reduction was the same in those who took a diuretic and those who took an ACE inhibitor. The incidence of stroke was the same in both groups, but the number of deaths from cardiovascular disease was 11 percent lower in the ACE inhibitor group.

Study author Dr. Christopher M. Reid of the Baker Heart Institute in Melbourne said that the differing results could have been due to the difference in the ethnic makeup of the two trials. He explained that thirty percent of the ALLHAT subjects were black Americans, who are known not to respond to ACE inhibitors, while the Australian study comprised mostly of whites. However, he also added that for most patients the conflicting results of the two trials will not make much difference, and that almost all people with high blood pressure need to take more than one drug. Reid said that their study recommended starting with an ACE inhibitor and then using a diuretic, if one is over the age of 65, while the ALLHAT study recommended starting with a diuretic and then adding a calcium channel blocker or an ACE inhibitor. Reid concluded that further research will lead to a situation where there will be specific recommendations for various groups of patients like the elderly, the diabetics, and the ethnic groups. He also stated that irrespective of the studies, the choice of agent that best suits the patient and the agent with which they are most compliant and comfortable would be the agent of choice.