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(Circulation. 2009;119:371-373.)
© 2009 American Heart Association, Inc.

Editorial

Antihypertensive Efficacy of Aliskiren

Is Hydrochlorothiazide an Appropriate Benchmark?

Franz H. Messerli, MD; Sripal Bangalore, MD

From the Division of Cardiology, St Luke’s and Roosevelt Hospitals, Columbia University College of Physicians and Surgeons, New York, NY (F.H.M.), and Division of Cardiology, Brigham and Women’s Hospital, Boston, Mass (S.B.).

Correspondence to Dr Franz H. Messerli, St. Luke’s-Roosevelt Hospital Center, 1000 Tenth Ave, New York, NY 10019. E-mail messerli.f@gmail.com

Key Words: Editorials • blood pressure • hypertension

An extract of the first 250 words of the full text is provided, because this article has no abstract.

The thorough prospective, randomized, double-blind trial of Schmieder et al¹ in the current issue of Circulation convincingly documents that aliskiren treatment provided significantly greater blood pressure (BP) reduction than hydrochlorothiazide. The study is well done; the number of patients (n=1124) is impressive; and the efficacy variables were analyzed, as is appropriate for an intention-to-treat population, with the last observation carried forward method. The authors concluded that aliskiren provided "more effective BP lowering than a thiazide-type diuretic, the drug class recommended by JNC 7 [Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure] guidelines² as first-line therapy for the treatment of hypertension." Indeed, not only JNC 7 but also JNC VI, V, IV, III, and I have recommended a thiazide-type diuretic, most commonly hydrochlorothiazide in the United States, as first-line therapy. Thus, over the years and decades, the JNC has elevated hydrochlorothiazide to the gold standard of antihypertensive therapy. Not surprisingly, therefore, hydrochlorothiazide remains the most prescribed drug in the United States. In 2007, >130 million prescriptions for hydrochlorothiazide, either alone or in combination, were written in this country. The doses of hydrochlorothiazide almost exclusively prescribed are 12.5 and 25 mg/d. This begs the question as to how solid the evidence is that hydrochlorothiazide in the dose of 12.5 to 25 mg reduces cardiovascular events (ie, stroke and heart attacks). A thorough scrutiny of the literature reveals little, if any, outcome evidence for low-dose hydrochlorothiazide. All outcome studies were done with higher doses, with hydrochlorothiazide in fixed . . . [Full Text of this Article]

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