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ACE INHIBITORS, CALCIUM ANTAGONISTS JOIN DIURETICS AND BETA BLOCKERS AS FIRST-LINE HYPERTENSION DRUG THERAPIES: BLOOD PRESSURE GROUP DRAFT REPORT

Executive Summary

ACE inhibitors and calcium channel blockers are useful as first line drug therapy for hypertension, the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure maintains in its just-completed draft report. "The 1984 report of the Joint National Committee . . . recommended that either thiazide-type diuretics or beta blockers be used as initial therapy, unless contraindications exist," the draft report states. "Clinical experience obtained since then would indicate that angiotensin converting enzyme inhibitors and calcium antagonists are also useful drugs for this purpose." Known as JNC IV, the draft report is the fourth on high blood pressure issued by the Joint National Committee since the group's founding by the National Heart, Lung and Blood Institute in 1972. A final report is expected in about three weeks and will be issued in the May 1988 issue of the Archives of Internal Medicine. "Calcium antagonists may be more effective in elderly patients than in the young as monotherapy for either diastolic or isolated systolic hypertension," the draft report explains. "Beta blockers and ACE inhibitors also may be useful as monotherapy in the elderly, but . . . studies have suggested that these drugs are less effective than diuretics or calcium antagonists." On the other hand, the draft report observes, some drugs "such as the direct-acting vasodilators (e.g., hydralazine, minoxidil) are not well suited for initial monotherapy since they often induce reflex sympathetic stimulation and fluid retention." For heart failure, the draft report specifically mentions Merck's ACE inhibitor product Vasotec (enalapril), which "when used in combination with digitalis and diuretics in patients with New York Heart Association Class IV congestive failure, has proven effective in reducing mortality due to progressive congestive heart failure." In addition, a clinical trial has also "indicated that hydralazine combined with isosorbide dinitrate significantly decreases mortality in patients with less severe (Class II and III) heart failure." One new area discussed in JNC IV is cost of drug therapy as it relates to patient compliance. "Newly introduced drugs usually cost more than traditional agents and may be priced too high for certain patients, thus diminishing their overall benefit by reducing adherence," it states. "Drugs that decrease the quality of life, although less expensive, also may reduce the overall benefit of treatment by reducing adherence." Noting that antihypertensive drug therapy has not been "convincingly demonstrated" to protect against the complications of coronary heart disease, the draft report recommends nonpharmacologic approaches, weight reduction and diet restriction, for example, as first line treatment. "A summary analysis of nine [antihypertensive] clinical trials shows a trend of reduced mortality from coronary artery disease in the intervention groups, but the difference did not reach statistical significance," the draft report states. "No long-term data are available as yet regarding the effects of alpha blockers, ACE inhibitors, or calcium antagonists on cardiovascular complications and mortality in hypertensive patients." The JNC also commented on nonpharmacologic approaches to treating hypertension, asserting that "nonpharmacologic modalities that are of value for hypertension management may be considered for primary prevention." Based on data from population studies, the JNC report says nonpharmacologic treatment may include restriction of sodium intake, weight reduction and moderation of alcohol consumption. With regard to other potential nonpharmacologic treatments, the report comments on the public attention that has been given to fish and fish oils in lowering the rate of coronary heart disease. "Fish that are rich in the polyunsaturated omega-3 fatty acids may lower blood levels of triglycerides and very-low-density-lipoprotein cholesterol," the report states. "However, fish oil supplementation can interfere with the ability of blood to clot, and, in some individuals, may cause excessive bleeding." Therefore, the JNC asserts, "while fish consumption is recommended, the health benefits of fish oil capsules have not been proven." Among other treatments, the report notes that "some epidemiologic data have suggested that reduced potassium intake may be associated with high blood pressure and that high potassium intake (i.e., total of greater than 80 mEq per day) has a modest blood-pressure-lowering effect." It concludes that data on calcium is inadequate to warrant making specific recommendations, as is evidence for use of magnesium, zinc and lead. In other recommendations, the report states that community-based hypertension programs "should increase their efforts to provide follow-up services -- patient tracking efforts that complement medical management." It adds that "there should be an ongoing commitment to remove economic barriers to adequate hypertension management in all settings in which economically disadvantaged patients are served."
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