Intervention Review

First-line drugs for hypertension

  1. James M Wright*,
  2. Vijaya M Musini

Editorial Group: Cochrane Hypertension Group

Published Online: 8 JUL 2009

Assessed as up-to-date: 31 MAR 2009

DOI: 10.1002/14651858.CD001841.pub2

How to Cite

Wright JM, Musini VM. First-line drugs for hypertension. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD001841. DOI: 10.1002/14651858.CD001841.pub2.

Author Information

  1. University of British Columbia, Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver, BC, Canada

*James M Wright, Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2176 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada. jim.wright@ti.ubc.ca.

Publication History

  1. Publication Status: New
  2. Published Online: 8 JUL 2009

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Sustained elevated blood pressure, unresponsive to lifestyle measures, leads to a critically important clinical question: What class of drug to use first-line? This review answers that question.

Objectives

Primary objective: To quantify the benefits and harms of the major first-line anti-hypertensive drug classes: thiazides, beta-blockers, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, alpha-blockers, and angiotensin II receptor blockers (ARB).

Search methods

Electronic search of MEDLINE (Jan. 1966-June 2008), EMBASE, CINAHL, the Cochrane clinical trial register, using standard search strategy of the hypertension review group with additional terms.

Selection criteria

Randomized trials of at least one year duration comparing one of 6 major drug classes with a placebo or no treatment. More than 70% of people must have BP >140/90 mmHg at baseline.

Data collection and analysis

The outcomes assessed were mortality, stroke, coronary heart disease (CHD), cardiovascular events (CVS), decrease in systolic and diastolic blood pressure, and withdrawals due to adverse drug effects. Risk ratio (RR) and a fixed effects model were used to combine outcomes across trials.

Main results

Of 57 trials identified, 24 trials with 28 arms, including 58,040 patients met the inclusion criteria.
Thiazides (19 RCTs) reduced mortality (RR 0.89, 95% CI 0.83, 0.96), stroke (RR 0.63, 95% CI 0.57, 0.71), CHD (RR 0.84, 95% CI 0.75, 0.95) and CVS (RR 0.70, 95% CI 0.66, 0.76). Low-dose thiazides (8 RCTs) reduced CHD (RR 0.72, 95% CI 0.61, 0.84), but high-dose thiazides (11 RCTs) did not (RR 1.01, 95% CI 0.85, 1.20).
Beta-blockers (5 RCTs) reduced stroke (RR 0.83, 95% CI 0.72, 0.97) and CVS (RR 0.89, 95% CI 0.81, 0.98) but not CHD (RR 0.90, 95% CI 0.78, 1.03) or mortality (RR 0.96, 95% CI 0.86, 1.07).
ACE inhibitors (3 RCTs) reduced mortality (RR 0.83, 95% CI 0.72-0.95), stroke (RR 0.65, 95% CI 0.52-0.82), CHD (RR 0.81, 95% CI 0.70-0.94) and CVS (RR 0.76, 95% CI 0.67-0.85).
Calcium-channel blocker (1 RCT) reduced stroke (RR 0.58, 95% CI 0.41, 0.84) and CVS (RR 0.71, 95% CI 0.57, 0.87) but not CHD (RR 0.77 95% CI 0.55, 1.09) or mortality (RR 0.86 95% CI 0.68, 1.09). No RCTs were found for ARBs or alpha-blockers.

Authors' conclusions

First-line low-dose thiazides reduce all morbidity and mortality outcomes. First-line ACE inhibitors and calcium channel blockers may be similarly effective but the evidence is less robust. First-line high-dose thiazides and first-line beta-blockers are inferior to first-line low-dose thiazides.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Thiazides best first choice for hypertension

One of the most important decisions in treating people with elevated blood pressure is what drug class is used first. This decision has enormous consequences in terms of health outcomes and cost. In this review health outcomes resulting from 4 drug classes are summarized. Most of the evidence demonstrated that first-line low-dose thiazides reduce mortality and morbidity (stroke, heart attack and heart failure). No other drug class improved health outcomes better than low-dose thiazides, and beta-blockers and high-dose thiazides were inferior. Low-dose thiazides should be the first choice drug in most patients with elevated blood pressure. Fortunately, thiazides are also very inexpensive.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

治療高血壓之第一線用藥

對調整生活型態無效之持續上升的血壓引發臨床上重要的議題:哪一類藥物應該是第一線用藥?這篇文章將答覆這個問題。

目標

主要目的:將主要第一線高血壓藥物,包含了: Thiazide 利尿劑,乙型阻斷劑,鈣離子阻斷劑,血管收縮素反轉脢抑制劑,血管張力素受器阻斷劑等藥物之好處及害處加以量化。

搜尋策略

搜查電子雜誌(1966年1月,2008年6月),醫學文摘庫,CINAHL,Cochrane臨床試驗登記,使用標準的高血壓搜索策略回顧族群及相關字詞。

選擇標準

隨機試驗中至少為期一年,比較6大類藥物之其中一種與安慰劑或不治療。超過 70%的人必須基礎血壓>140/90毫米汞柱。

資料收集與分析

預後評估的項目包含死亡,中風,冠心病(CHD),心血管事件(CVS),收縮壓和舒張壓的下降,和由於藥物不良影響而退出試驗。風險率(RR)和固定效應模型被用來在不同試驗相結合的預後評估。

主要結論

57個試驗發現,24個臨床試驗包含了28組,其中包括58040例符合納入標準。Thiazide利尿劑(19個隨機對照試驗)降低死亡率(風險率0.89,95%信賴區間為 0.83,0.96),中風(風險率0.63,95%信賴區間為 0.57,0.71),冠心病(風險率0.84,95%CI為 0.75,0.95)和心血管事件(風險率0.70, 95%信賴區間為 0.66,0.76)。低劑量Thiazide利尿劑(8個隨機對照試驗)降低冠心病(風險率0.72,95%信賴區間為 0.61,0.84),但高劑量Thiazide利尿劑(11個隨機對照試驗)沒有降低冠心病(風險率1.01,95%信賴區間為 0.85,1.20)。 乙型阻斷劑(5個隨機對照試驗)減少中風(風險率0.83,95%信賴區間為 0.72,0.97)和心血管事件(風險率0.89,95%信賴區間為 0.81,0.98),但冠心病(風險率0.90,95%信賴區間為 0.78,1.03)和死亡率則無改變(風險率0.96,95%信賴區間為 0.86,1.07)。 血管收縮素反轉脢抑制劑(3個隨機對照試驗)降低死亡率(風險率0.83,95%信賴區間為 0.72 – 0.95),中風(風險率0.65,95%信賴區間為 0.52 – 0.82),冠心病(風險率0.81,95%信賴區間為 0.70 – 0.94)和心血管事件(風險率0.76 ,95%信賴區間為 0.67 – 0.85)。鈣離子阻斷劑(1個隨機對照試驗)降低了中風(風險率0.58,95%信賴區間為 0.41,0.84)和心血管事件(風險率0.71,95%CI為 0.57,0.87),但冠心病(風險率0.77 95%信賴區間為 0.55,1.09)和死亡率則無改變(風險率0.86 95%信賴區間為 0.68,1.09)。血管張力素受器阻斷劑和甲型受體阻滯劑則沒有隨機對照試驗證實。

作者結論

第一線低劑量Thiazide利尿劑降低所有發病率和死亡率的預後。第一線使用血管收縮素反轉脢抑制劑和鈣離子阻斷劑可能同樣有效,但證據是較不足夠的。第一線使用大劑量Thiazide利尿劑和第一線使用乙型阻斷劑不如第一線使用低劑量Thiazide利尿劑。

翻譯人

本摘要由臺北榮民總醫院鐘法博翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

首選藥物為何是治療高血壓的病人其中一個最重要的決定。此決定對於健康結果有著巨大後果的影響。這次回顧總結了4類藥物所造成對健康的預後。大部分的證據證明,第一線低劑量Thiazide利尿劑降低死亡率和發病率(中風,心臟病發作和心衰竭)。對於改善健康的預後,沒有任何其他類藥物優於低劑量Thiazide利尿劑,而乙型阻斷劑和高劑量Thiazide利尿劑則是較差的。低劑量Thiazide利尿劑應該是大多數高血壓患者的首選藥物。幸運的是,Thiazide利尿劑也很便宜。