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Efficacy of Different Drug Classes Used to Initiate Antihypertensive Treatment in Black Subjects
Results of a Randomized Trial in Johannesburg, South Africa
Pinhas Sareli, MD;
Ivelin V. Radevski, MD;
Zdravka P. Valtchanova, MD;
Elena Libhaber, MSc;
Geoffrey P. Candy, MSc;
Elly Den Hond, DSc;
Carlos Libhaber, MD;
Daniel Skudicky, MD;
Ji G. Wang, MD;
Jan A. Staessen, MD
Arch Intern Med. 2001;161:965-971.
Background Thiazides are recommended to initiate antihypertensive drug treatment
in black subjects.
Objective To test the efficacy of this recommendation in a South African black
cohort.
Methods Men and women (N = 409), aged 18 to 70 years, with a mean ambulatory
daytime diastolic blood pressure between 90 and 114 mm Hg, were randomized
to 13 months of open-label treatment starting with the nifedipine gastrointestinal
therapeutic system (30 mg/d, n = 233), sustained-release verapamil hydrochloride
(240 mg/d, n = 58), hydrochlorothiazide (12.5 mg/d, n = 58), or enalapril
maleate (10 mg/d, n = 60). If the target of reducing daytime diastolic blood
pressure below 90 mm Hg was not attained, the first-line drugs were titrated
up and after 2 months other medications were added to the regimen.
Results While receiving monotherapy (2 months, n = 366), the patients' systolic
and diastolic decreases in daytime blood pressure averaged 22/14 mm Hg for
nifedipine, 17/11 mm Hg for verapamil, 12/8 mm Hg for hydrochlorothiazide,
and 5/3 mm Hg for enalapril. At 2 months the blood pressure of more patients
treated with nifedipine was controlled: 133 (63.3%, P .03)
vs 20 (39.9%) receiving verapamil, 21 (40.4%) receiving hydrochlorothiazide,
and 11 (20.8%) receiving enalapril. At 13 months (n = 257), more patients
(P<.001) continued receiving monotherapy with
nifedipine (94/154 [61.0%]) or verapamil (22/35 [62.9%]) than hydrochlorothiazide
(10/39 [25.6%]) or enalapril (1/29 [3.4%]). A sustained decrease of left ventricular
mass (P<.001) with no between-group differences
was achieved at 4 and 13 months.
Conclusions In contrast to current recommendations, calcium channel blockers are
more effective than thiazides as initial treatment in black subjects with
hypertension. If treatment is started with thiazides or converting-enzyme
inhibitors, combination therapy is more likely to be required to control blood
pressure and reduce left ventricular mass.
From the Department of Cardiology, Chris Hani-Baragwanath Hospital,
University of the Witwatersrand, Johannesburg, South Africa (Drs Sareli, Radevski,
Valtchanova, C. Libhaber, and Skudicky, and Mr Candy and Ms E. Libhaber);
and the Study Coordinating Centre, Hypertension and Cardiovascular Rehabilitation
Unit, Department of Molecular and Cardiovascular Research, University of Leuven,
Leuven, Belgium (Drs Den Hond, Wang, and Staessen).
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