Water Pill Works Best for High Blood Pressure

Diuretics Are Best First Choice for African Americans, Others

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April 5, 2005 -- African Americans are roughly three times as likely as whites to die of illnesses caused by high blood pressure.

That increased risk is so great that what defines good blood pressure control is now lower for African Americans than for whites, but new research shows that in this group, water pills remain the drug of choice for the initial treatment of high blood pressure.

Using data from a landmark high blood pressure study, researchers showed that the oldest and cheapest blood pressure medications work better as the initial treatment for high blood pressure, in both African Americans and other races, than newer, more expensive drugs.

The findings show that thiazide-type diuretics, known as water pills, which cost just pennies a pill, are a better choice for the initial treatment of high blood pressure than the newer drugs, known as ACE inhibitors and calcium-channel blockers.

Is Blood Pressure Treatment Colorblind?

Though nearly one in three American adults have high blood pressure, the figure is closer to one in two for African Americans.

Because of this, the American Heart Association and other health groups recommend more aggressive blood pressure treatment for African Americans than for other racial groups. The normal goal of treatment is to reduce blood pressure to below 140/90. But the goal for African Americans is now 130/80.

In the newly published study, researchers analyzed data from a subgroup of participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Their goal was to look at the risk of heart disease and death from heart disease in African Americans with high blood pressure taking one of the three commonly prescribed medications.

When first published in 2002, ALLHAT challenged the pervasive thinking that newer blood pressure drugs worked better to treat high blood pressure and prevent some forms of heart disease than water pills, which have been used to treat high blood pressure for many decades. The ALLHAT study showed that a water pill worked better.

ALLHAT researcher Jackson T. Wright Jr., MD, PhD, says the trial has not affected clinical practice to the extent that he had hoped.

"The message has not really gotten out," he says. "There has been a slight increase in diuretic use, but not to the extent that one would anticipate from the data that are now available."

Participants in the ALLHAT study, which was done between 1994 and 2002, took one of three drugs to lower their blood pressure, a leading cause of heart disease. They were given one of three commonly prescribed blood pressure medications: the diuretic Hygroton, the ACE inhibitor lisinopril, or the calcium-channel blocker Norvasc.

Among the new findings reported by Wright and colleagues in the April 6 issue of The Journal of the American Medical Association:

  • African Americans who took the diuretic achieved better blood pressure control than those who took the other drugs.
  • Diuretics were better than the two newer drugs for reducing the rates of heart failure in African Americans. Among non-African Americans, those who took calcium-channel blockers had the highest risk of heart failure.
  • Neither of the two newer drugs was more effective than the diuretic for preventing heart attacks or death from heart disease in African Americans and non-African Americans.
  • The findings showed that ACE inhibitors are less effective than other drugs for lowering blood pressure and preventing poor outcomes in African Americans. African Americans who took ACE inhibitors had a 40% greater risk of stroke, a 30% greater risk of heart failure, and a 19% greater risk for cardiovascular events than those who took the diuretic.

"The overall ALLHAT conclusions that thiazide-type diuretics are indicated as the drug of choice for initial therapy of hypertension apply to both blacks and non-black patient populations," the researchers conclude.

They also recommend calcium-channel blockers over ACE inhibitors as the initial treatment for African Americans who cannot take a diuretic.

'Issue Has Been Settled'

In an editorial accompanying the new findings, James Neaton, PhD, of the University of Minnesota School of Public Health, agrees that diuretics are the clear first choice for all patients with high blood pressure who can take them, regardless of race.

Most patients end up needing a combination of several types of blood pressure drugs to adequately control their hypertension, however.

"It is now time to move beyond comparisons of diuretics with other classes of blood pressure-lowering drugs; that issue has been settled," he writes. "Determining how to lower blood pressure to more optimal levels in the most cost-effective manner and in the populations at risk is the new priority."

Wright admits to being frustrated that so few people with high blood pressure who could be benefiting from diuretics are taking the cheap and highly effective drugs.

"It is unfortunate that [doctors] still shy away from giving a diuretic at all or from giving diuretics in adequate doses to control blood pressure," he says.

Show Sources


The Journal of the American Medical Association: “Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril.”

Jackson T. Wright Jr., MD, PhD, General Clinical Research Center, Case Western Reserve University, Cleveland.

James D. Neaton, PhD, Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis.

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