Context Antihypertensive therapy is well established to reduce hypertension- related morbidity and mortality, but the optimal first-step therapy is unknown. Objective To determine whether treatment with a calcium channel blocker or an angiotensin-converting enzyme inhibitor lowers the incidence of coronary heart dis- ease (CHD) or other cardiovascular disease (CVD) events vs treatment with a diuretic. Design The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart At- tack Trial (ALLHAT), a randomized, double-blind, active-controlled clinical trial con- ducted from February 1994 through March 2002. Setting and Participants A total of 33357 participants aged 55 years or olderwith hypertension and at least 1 other CHD risk factor from 623 North American centers. Interventions Participants were randomly assigned to receive chlorthalidone, 12.5 to 25 mg/d (n=15255); amlodipine, 2.5 to 10 mg/d (n=9048); or lisinopril, 10 to 40 mg/d (n=9054) for planned follow-up of approximately 4 to 8 years. Main Outcome Measures The primary outcome was combined fatal CHD or non- fatal myocardial infarction, analyzed by intent-to-treat. Secondary outcomes were all- cause mortality, stroke, combined CHD (primary outcome, coronary revascularization, or angina with hospitalization), and combined CVD (combined CHD, stroke, treated an- gina without hospitalization, heart failure [HF], and peripheral arterial disease). Results Mean follow-up was 4.9 years. The primary outcome occurred in 2956 par- ticipants, with no difference between treatments. Compared with chlorthalidone (6- year rate, 11.5%), the relative risks (RRs) were 0.98 (95% CI, 0.90-1.07) for amlo- dipine (6-year rate, 11.3%) and 0.99 (95% CI, 0.91-1.08) for lisinopril (6-year rate, 11.4%). Likewise, all-cause mortality did not differ between groups. Five-year sys- tolic blood pressures were significantly higher in the amlodipine (0.8 mm Hg, P=.03) and lisinopril (2 mm Hg, P=.001) groups compared with chlorthalidone, and 5-year diastolic blood pressure was significantly lower with amlodipine (0.8mmHg, P?.001). For amlodipine vs chlorthalidone, secondary outcomes were similar except for a higher 6-year rate of HF with amlodipine (10.2% vs 7.7%; RR, 1.38; 95% CI, 1.25-1.52). For lisinopril vs chlorthalidone, lisinopril had higher 6-year rates of combined CVD (33.3% vs 30.9%; RR, 1.10; 95% CI, 1.05-1.16); stroke (6.3% vs 5.6%; RR, 1.15; 95% CI, 1.02-1.30); and HF (8.7% vs 7.7%; RR, 1.19; 95% CI, 1.07-1.31). Conclusion Thiazide-type diuretics are superior in preventing 1 or more major forms of CVD and are less expensive. They should be preferred for first-step antihypertensive therapy.
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