Diuretics Better Than ACE Inhibitors as Initial Hypertension Treatment, Analysis Suggests

By Amy Orciari Herman

Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS

In patients beginning hypertension monotherapy, diuretics are a more effective and safer option than angiotensin-converting enzyme (ACE) inhibitors, according to a large, retrospective, industry-funded analysis in The Lancet.

Using nine healthcare databases from the U.S., Germany, Japan, and South Korea, researchers studied nearly 5 million patients who began treatment with a single antihypertensive agent: ACE inhibitors (48% of patients), diuretics (17%), dihydropyridine calcium channel blockers (16%), angiotensin receptor blockers (15%), or non-dihydropyridine calcium channel blockers (3%). The researchers examined nine effectiveness outcomes and 46 safety outcomes across the drug classes.

Most effectiveness comparisons across drug classes showed no significant differences. However, compared with ACE inhibitors, diuretics were associated with significantly lower risks for myocardial infarction, heart failure hospitalization, and stroke (roughly a 15% risk reduction for each). Diuretics were also "markedly better" than ACE inhibitors in terms of safety. Non-dihydropyridine calcium channel blockers appeared least effective.

Commentators write, "These data provide evidence that [thiazide diuretics] are more effective in preventing health outcomes and are underused given their tolerable side-effect profile."