No evidence to support the use of
hydrochlorothiazide for 24-h blood pressure control
Objective:
To asses the efficacy of hydrochlorothiazide on 24-h blood pressure (BP)
control.
Methods:
Review of all the randomized trials that assessed 24-h BP with
hydrochlorothiazide (HCTZ) compared with other antihypertensive drugs.
Meta-analysis of:
- 14 studies of HCTZ dose 12.5 to 25 mg,
- 5 studies of HCTZ dose 50 mg.
1. Messerli FH et al. J Am Coll Cardiol. 2011;57:590-600.
HCTZ: inferior 24-h BP control
HCTZ
ACE
inhibitors
ARBs
Beta
Blockers
Calcium
Antagonists
BP Reduction (mm Hg)
0
-5
N=14
-10
N=3
-15
Systolic BP
N=5
N=5
Diastolic BP
-20
N=7
Efficacy of hydrochlorothiazide, assessed by 24-h ABPM1 (Adapted from Messerli FH et al. J Am Coll Cardiol. 2011;57:590-600)
Compared with hydrochlorothiazide (HCTZ) dose 12.5 to 25 mg, P< 0.001 for other antihypertensive drugs, as assessed by 24-h ambulatory blood pressure
(ABP) monitoring.
Bars = 95% confidence intervals
N = number of studies
ACE = angiotensin-converting enzyme
ARBs = angiotensin-receptor blockers
1. Messerli FH et al. J Am Coll Cardiol. 2011;57:590-600.
“Not all diuretics are equal”
HCTZ 12.5 - 25 mg/day does not reduce stroke and heart attack, or death.2,3
The diuretics shown to reduce cardiovascular morbidity and mortality are
chlorthalidone in SHEP and ALLHAT, and indapamide in HYVET, PROGRESS,
and ADVANCE
4
5
Fatal stroke
-39%
Fatal or nonfatal stroke
Stroke
-43%
6
Total mortality
-14%
-30%
Cardiovascular mortality
-18%
Heart failure
-64%
Renal events
-21%
Total mortality
-21%
2. Gaciong Z, Symonides B. Expert Opin. Pharmacother. 2010;11:2579-2597. 3. Kaplan NM. Hypertension. 2009;54:951-953. 4. Beckett NS, Peters R, Fletcher AE, et al. N Engl J
Med. 2008;358:1887-1898. 5. PROGRESS Collaborative Group. Lancet. 2001;358:1033–1041. 6. ADVANCE Collaborative Group. Lancet. 2007;370:829-840.
CONCLUSIONS
The efficacy on 24-h blood pressure control of HCTZ at its usual
daily doses, of 12.5 to 25 mg/day is inferior to that of all other
antihypertensive drug classes.1
There are no data showing that HCTZ 12.5 - 25 mg/day reduces
heart attack and stroke or death.2
The authors of the meta-analysis concluded that:
“if a clinical indication calls for a thiazide-type diuretic,
chlorthalidone or indapamide remain the drugs of choice”.1
1. Messerli FH et al. J Am Coll Cardiol. 2011;57:590-600. 2. Gaciong Z, Symonides B. Expert Opin. Pharmacother. 2010;11:2579-2597.