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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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