By: Thomas Pickering, MD, DPhil, FRCP, Director of Integrative and Behavioral Cardiology Program
of the Cardiovascular Institute at Mount Sinai School of Medicine, New York.

Although beta blockers and diuretics are still recommended as first-line treatment for hypertension, the newer drugs such as ACE inhibitors and calcium channel blockers are becoming increasingly popular, and in the US account for 55% of antihypertensive prescriptions. The rationale is that they are more effective and better tolerated, but is this true? A new German study called HANE (for Hydrochlorothiazide, Atenolol, Nitrendipine, Enalapril) has attempted to answer this question, with some surprising results.

The study was conducted in 868 hypertensive subjects, who were randomly allocated to one of four treatments: 12.5 mgs of Hydrochlorothiazde (a diuretic), 25 mgs of Atenolol (a beta blocker), 10 mgs of Nitrendipine (a calcium channel blocker), or 5 mgs of Enalapril (an ACE inhibitor), with doubling of the dose of each drug if needed. The response rate was defined as the percentage of patients whose blood pressure was lowered to a diastolic of 90 mm Hg or below.

After eight weeks of treatment, the response rate was best in the group treated with atenolol (64%); it was 50% for enalapril, 45% for both hydrochlorothiazide and nitrendipine. The response rate was lower after one year of treatment for all groups, but atenolol was no longer superior to enalapril. The dropout rate from side effects of treatment was higher in the group given nitrendipine than the other drugs. A surprising finding was that women responded better to enalapril than men (59% versus 42% responders). Both hydrochlorothiazide and nitrendipine worked better in older than in younger patients.

Doctor’s comments

The success of the newer agents, such as ACE inhibitors and calcium channel blockers, in the treatment of hypertension is more the result of effective marketing by pharmaceutical companies than any scientific demonstration of their superiority. Diuretics and beta blockers are not only cheaper but also more thoroughly tested than the newer agents, and this study shows that they work just as well or better. One of the other points made by the study is that none of the drugs work well in everyone, and that at the present time, we don’t have any very good method of predicting which drug will work in which individual.

Where it was published