Response to Letter Regarding Article, “Role of Diuretics in the Prevention of Heart Failure: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)”
We thank Drs Ben-Dov and Bursztyn for their thoughtful letter regarding our article1 and the role of clinic versus ambulatory blood pressure in assessing the relative impact of antihypertensive treatments on clinical outcomes, especially heart failure. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was designed to allow for recruitment and retention of a large number of patients, with minimal burden to the providers and study participants and a cost structure that could be achieved and sustained over a long period of follow-up. As such, there was much information not collected within ALLHAT that could have provided insight into the study’s results.2 Recording of ambulatory blood pressure on a subset of the ALLHAT patients, in addition to clinic blood pressure, might have revealed greater blood pressure differences than were observed. One such ambulatory blood pressure substudy was conducted within the framework of the Health Outcomes Prevention Evaluation Trial.3 This study showed greater falls in ambulatory blood pressure, especially at night, than office blood pressure for those on ramipril versus those on placebo. Therefore, we agree that future large-scale hypertension trials comparing treatments should include a substudy of ambulatory blood pressure monitoring.
Dr Davis has worked as a consultant for Takeda, Merck, and GlaxoSmithKline. Dr Franklin has served on speakers’ bureaus for Boehringer Ingelheim, Merck, and Bristol-Myers Squibb; as an expert witness for La Follette, Johnson, De Haas, Fesler & Ames, Los Angeles, Calif, and Gordon, Thomas, Honeywell, Malanca, Peterson, & Daheim LLP, Seattle, Wash; and as a consultant for AtCor Medical, Inc. Dr. Leenen has received honoraria from Pfizer; has ownership interest in Bristol-Myers Squibb, Merck, Johnson and Johnson, and Schering Plough; and has worked as a consultant for Pfizer. Dr Mohiuddin has worked on research grants funded by Health Future Foundation, Nebraska Tobacco Settlement Biomedical Research Development Grants, and AstraZeneca; has served on the speakers’ bureau for AstraZeneca; has received honoraria from the American College of Cardiology and AstraZeneca; has ownership interest in Pfizer, Johnson and Johnson, and Abbott Laboratories; and has served as a consultant for Pfizer and AstraZeneca. Dr Papademetriou has received research grants from AstraZeneca; has worked on the speakers’ bureau for AstraZeneca; and has received honoraria from AstraZeneca. The other authors report no conflicts of interest.
Davis BR, Piller LB, Cutler JA, Furberg C, Dunn K, Franklin S, Goff D, Leenen F, Mohiuddin S, Papademetriou V, Proschan M, Ellsworth A, Golden J, Colon P, Crow R; Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Collaborative Research Group. Role of diuretics in the prevention of heart failure: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Circulation. 2006; 113: 2201–2210.
Svensson P, de Faire U, Sleight P, Yusuf S, Östergren J. Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE substudy. Hypertension. 2001; 38: e28–e32.