Clinical events in high-risk hypertensive patients randomly assigned to calcium channel blocker versus angiotensin-converting enzyme inhibitor in the antihypertensive and lipid-lowering treatment to prevent heart attack trial.
The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) provides a unique opportunity to compare the long-term relative safety and efficacy of angiotensin-converting enzyme inhibitor and calcium channel blocker-initiated therapy in older hypertensive individuals. Patients were randomized to amlodipine (n=9048) or lisinopril (n=9054). The primary outcome was combined fatal coronary heart disease or nonfatal myocardial infarction, analyzed by intention-to-treat. Secondary outcomes included all-cause mortality, stroke, combined cardiovascular disease (CVD), end-stage renal disease (ESRD), cancer, and gastrointestinal bleeding. Mean follow-up was 4.9 years. Blood pressure control was similar in nonblacks, but not in blacks. No significant differences were found between treatment groups for the primary outcome, all-cause mortality, ESRD, or cancer. Stroke rates were higher on lisinopril in blacks (RR=1.51, 95% CI 1.22 to 1.86) but not in nonblacks (RR=1.07, 95% CI 0.89 to 1.28), and in women (RR=1.45, 95% CI 1.17 to 1.79), but not in men (RR=1.10, 95% CI 0.92 to 1.31). Rates of combined CVD were higher (RR=1.06, 95% CI 1.00 to 1.12) because of higher rates for strokes, peripheral arterial disease, and angina, which were partly offset by lower rates for heart failure (RR=0.87, 95% CI 0.78 to 0.96) on lisinopril compared with amlodipine. Gastrointestinal bleeds and angioedema were higher on lisinopril. Patients with and without baseline coronary heart disease showed similar outcome patterns. We conclude that in hypertensive patients, the risks for coronary events are similar, but for stroke, combined CVD, gastrointestinal bleeding, and angioedema are higher and for heart failure are lower for lisinopril-based compared with amlodipine-based therapy. Some, but not all, of these differences may be explained by less effective blood pressure control in the lisinopril arm.
Leenen
Frans H H
FH
University of Ottawa Heart Institute, Ottawa, Ontario, Canada. fleenen@ottawaheart.ca
Nwachuku
Chuke E
CE
Black
Henry R
HR
Cushman
William C
WC
Davis
Barry R
BR
Simpson
Lara M
LM
Alderman
Michael H
MH
Atlas
Steven A
SA
Basile
Jan N
JN
Cuyjet
Aloysius B
AB
Dart
Richard
R
Felicetta
James V
JV
Grimm
Richard H
RH
Haywood
L Julian
LJ
Jafri
Syed Z A
SZ
Proschan
Michael A
MA
Thadani
Udho
U
Whelton
Paul K
PK
Wright
Jackson T
JT
D017311:Amlodipine / Q000627:therapeutic use*; D000799:Angioedema / Q000453:epidemiology / Q000209:etiology; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D044383:Black People / Q000706:statistics & numerical data; D001786:Blood Glucose / Q000378:metabolism; D001794:Blood Pressure; D002121:Calcium Channel Blockers / Q000627:therapeutic use*; D002303:Cardiac Output, Low / Q000453:epidemiology / Q000209:etiology; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000209:etiology; D003327:Coronary Disease / Q000209:etiology; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology / Q000209:etiology; D005919:Glomerular Filtration Rate; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000188:drug therapy* / Q000208:ethnology / Q000503:physiopathology; D017379:Hypertrophy, Left Ventricular; D000960:Hypolipidemic Agents / Q000627:therapeutic use*; D015994:Incidence; D017706:Lisinopril / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control*; D012306:Risk; D017678:Sex Distribution
D000806:Angiotensin-Converting Enzyme Inhibitors; D001786:Blood Glucose; D002121:Calcium Channel Blockers; D000960:Hypolipidemic Agents; D017311:Amlodipine; D017706:Lisinopril