Hypertension Treatment With Diuretics Recommended In New Guide ScienceDaily (May 23, 2008) — A study based at The University of Texas Health Science Center at Houston provides added justification that a thiazide-type diuretic is the best first-choice drug for hypertensive patients. The ALLHAT antihypertensive trial results led to a conclusion that inexpensive thiazide-type diuretics are superior to an ACE-inhibitor, a calcium channel blocker and an alpha-receptor blocker in preventing one or more major forms of CVD. They should be preferred first-step antihypertensive therapy. According to the American Heart Association, about one in three U.S. adults has high blood pressure. Uncontrolled high blood pressure can lead to stroke, heart attack, heart failure or kidney failure. A joint national committee (JNC) on the prevention, detection and evaluation of high blood pressure meets on a regular basis to summarize suggested guidelines for doctors on treating hypertension based on medical research.  The findings of the JNC are based on information stemming from a landmark investigation at the UT School of Public Health, which in 2002 established that diuretics were "as good or better" than three other classes of medications for high blood pressure. The original investigation was called ALLHAT - Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. "We found that further analyses of the original ALLHAT trial and information from more recent studies confirmed the original findings that diuretics are the preferred choice for antihypertensive therapy, alone or in combination with other drugs," said Barry Davis, M.D., Ph.D., professor of biostatistics and the director of the Coordinating Center for Clinical Trials at the UT School of Public Health. "Five years after the ALLHAT results were published, the JNC recommendation still holds," added Davis, who co-authored the study with Jeffrey A. Cutler, M.D., MPH, a consultant to the National Heart, Lung and Blood Institute (NHLBI). The most recent committee highlighted ALLHAT's findings in the revision of its guidelines, meaning the information will now be used for practical treatments. The committee states that when compared to calcium channel blockers, ACE inhibitors and alpha blockers, thiazide-type diuretics are better first-line drug treatments for hypertensive patients. The diuretics excelled in controlling blood pressure, preventing cardiovascular events, are well tolerated by patients and are relatively inexpensive. Original ALLHAT findings appear in two articles in a 2002 issue of The Journal of the American Medical Association (JAMA). The project consisted of two clinical trials: one compared a diuretic with newer and more expensive antihypertensive drugs to start blood pressure-lowering treatment to ascertain which was best at preventing cardiovascular outcomes; the other compared a statin drug to usual care in lowering cholesterol levels to determine if treatment would lower the occurrence of deaths over the study period. The articles and details of the study and its findings can be found on the study's web site, http://www.allhat.org. The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by University of Texas Health Science Center at Houston. Journal Reference: Thiazide-type diuretics and beta-adrenergic blockers as first-line drug treatments for hypertension. American Heart Association's Circulation. Volume 117, Issue 20

I would like to beg your pardon if I am not up to date on this subject.
I have not been an actively practicing physician for a while.
Please correct me if you find any errors.

The 8th report of JNC (JNC8, Update of JNC7) is to be released in the fall of 2011.
So, JNC7 seems to be the latest recommendation at this time.

JNC7 Recommendations:

In 2003, the Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC7) issued its recommendations
on the basis of the ALLHAT results and other trial evidence that was available at that time.
49 Its major conclusions and recommendations were as follows. (partially copied here)

In trials comparing thiazide-type diuretics with other classes of antihypertensive agents,
they are (compared to other fancy expensive antihypertensive drugs - AB, BB, CCB, ACEI...)
(1) well tolerated;
(2) effective and relatively safe for the management of hypertension
despite potential adverse metabolic effects; and
(3) unsurpassed in preventing the cardiovascular complications of hypertension.

They are also less expensive and underutilized.
The doses of thiazide-type diuretics used in successful morbidity trials of
low/moderate-dose diuretics should be used (generally the equivalent of
25 to 50 mg of hydrochlorothiazide or 12.5 to 25 mg of chlorthalidone),
although therapy may be initiated at lower doses and titrated to these doses if tolerated.

I've been heavily involved in the treatment of hypertension for over 40 years throughout my career
in cardiovascular disease. The above are a couple of useful informations.
However, treating hypertension in each individual requires a great deal of consideration of
the person's age, family history, comorbid conditions, life style, weight, personality, sex, occupation,
and many other factors, with ample knowledge of cardiovascular physiology and pharmacology
on the part of the treating physician.

Here I'd like to share a couple of practical informations that the doctors and the patients
should be aware of.
First, a warning, that is,
Do not buy the automatic blood pressure cuff with digital read out that shows blood pressure numbers.
So many people buy this which cost $50-100. Some are designed to put it around the upper arm and
some around the wrists. These do not have enough computer chips to make the reading accurate.
The ones they use at the hospital, called"dynamo", cost the hospital a $1000 a piece.
These thousand dollar ones are not accurate half of the time so that every now and then RN has to
check it out with the conventional cuff.
Another problem with the cheap automatic cuff is that it does not move pararell with the fluctuation of
the true blood pressure.
If you compare the reading of this cuff with your conventional BP measurement with your cuff and
stethoscope, you will find that the automatic cuff will give you approximately 20 mm Hg
higher reading than the conventional reading.

In pediatric Cardiology, I'm proud to say that our alumni member, Dr. Myung K. Park(박명근 '60) studied
this problem extensively and straightened out the problem by developing a reference table for children.
He wrote a textbook, "Pediatric Cardiology for Practitioners" which detailed this problem.
In adult Cardiology, we have a total mess with this problem mainly because most of the physicians
are not aware of this problem so that for the last twenty years
the situation is like the blinds lead the blinds.
To compound the problem, our interns and residents and young practitioners
do not carry blood pressure cuff and the physician's bag anymore so that
they do not know there is such a problem. They finish the training and
go into practice and tell their patients to buy the cheap blood pressure machines.

The second advice is to measure the blood pressure in both arms and
in lying, sitting and standing positions.
You keep on taking blood pressures not once, but multiple times
until you have stable rock bottom pressures.
You'll be surprised how much fluctuation there is in that short period of time.
For seniors, it is vital to know the standing blood pressure and
the function of baroreceptos in different positions against the gravity,
particulary when they are taking BP medicines.

 

Dr. Lee;
Thanks a million on your input.
I check my BP with self-inflating automatic (bought from Walgreen) electronic one.
I get somewhat variable reading of 160-140/95-85.
As you said, in a same sitting I get these variable results !! Confusing.

One time at doctor's office, I was measured with manual machine at 130/80 by a PA.
(with current mess in medical care system, I stay away from doctor's office.)
So, what you are saying may be true !!

I guess I need to buy a manual one with mercury column measuring.

I was seriously considering BP medications as a borderline hypertension.
I have not gotten into it yet.

I'm glad you found my warning useful.
They don't sell the cuff with mercury column anymore for fear of mercury poisoning.
You buy one with rubber bladder with a dial, the standardized cuff by Tyco.
There is a regular size for an average arm circumference, and
a larger one with larger rubber bladder for a big arm circumference.
It is advisable to use the right size. You are an athlete so that your arm circumference
may be greater than that of average. If it is, the blood pressure reading may register higher than
the true pressure. The rubber bladder should go around roughly 2/3 of the circumference.
The price of the cuff is around $200, and you need a stethoscope.
If you don't have diastolic hypertension, you do not need stethoscope.
You just measure the systolic blood pressure by the palpation of your radial pulse, if you
remember how to.
The systolic BP measured by the palpation method may be more accurate if you have
a hearing problem.