Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).
BACKGROUND
Antihypertensive drugs with favorable metabolic effects are advocated for first-line therapy in hypertensive patients with metabolic/cardiometabolic syndrome (MetS). We compared outcomes by race in hypertensive individuals with and without MetS treated with a thiazide-type diuretic (chlorthalidone), a calcium channel blocker (amlodipine besylate), an alpha-blocker (doxazosin mesylate), or an angiotensin-converting enzyme inhibitor (lisinopril).


METHODS
A subgroup analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind hypertension treatment trial of 42 418 participants. We defined MetS as hypertension plus at least 2 of the following: fasting serum glucose level of at least 100 mg/dL, body mass index (calculated as weight in kilograms divided by height in meters squared) of at least 30, fasting triglyceride levels of at least 150 mg/dL, and high-density lipoprotein cholesterol levels of less than 40 mg/dL in men or less than 50 mg/dL in women.


RESULTS
Significantly higher rates of heart failure were consistent across all treatment comparisons in those with MetS. Relative risks (RRs) were 1.50 (95% confidence interval, 1.18-1.90), 1.49 (1.17-1.90), and 1.88 (1.42-2.47) in black participants and 1.25 (1.06-1.47), 1.20 (1.01-1.41), and 1.82 (1.51-2.19) in nonblack participants for amlodipine, lisinopril, and doxazosin comparisons with chlorthalidone, respectively. Higher rates for combined cardiovascular disease were observed with lisinopril-chlorthalidone (RRs, 1.24 [1.09-1.40] and 1.10 [1.02-1.19], respectively) and doxazosin-chlorthalidone comparisons (RRs, 1.37 [1.19-1.58] and 1.18 [1.08-1.30], respectively) in black and nonblack participants with MetS. Higher rates of stroke were seen in black participants only (RR, 1.37 [1.07-1.76] for the lisinopril-chlorthalidone comparison, and RR, 1.49 [1.09-2.03] for the doxazosin-chlorthalidone comparison). Black patients with MetS also had higher rates of end-stage renal disease (RR, 1.70 [1.13-2.55]) with lisinopril compared with chlorthalidone.


CONCLUSIONS
The ALLHAT findings fail to support the preference for calcium channel blockers, alpha-blockers, or angiotensin-converting enzyme inhibitors compared with thiazide-type diuretics in patients with the MetS, despite their more favorable metabolic profiles. This was particularly true for black participants.
Wright
Jackson T
JT
Department of Medicine, General Clinical Research Center, Cleveland, Ohio, USA.
Harris-Haywood
Sonja
S
Pressel
Sara
S
Barzilay
Joshua
J
Baimbridge
Charles
C
Bareis
Charles J
CJ
Basile
Jan N
JN
Black
Henry R
HR
Dart
Richard
R
Gupta
Alok K
AK
Hamilton
Bruce P
BP
Einhorn
Paula T
PT
Haywood
L Julian
LJ
Jafri
Syed Z A
SZ
Louis
Gail T
GT
Whelton
Paul K
PK
Scott
Cranford L
CL
Simmons
Debra L
DL
Stanford
Carol
C
Davis
Barry R
BR
D000368:Aged; D000369:Aged, 80 and over; D017311:Amlodipine / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D044383:Black People; D002752:Chlorthalidone / Q000627:therapeutic use; D004311:Double-Blind Method; D017292:Doxazosin / Q000627:therapeutic use; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000208:ethnology*; D017706:Lisinopril / Q000627:therapeutic use; D008297:Male; D024821:Metabolic Syndrome / Q000188:drug therapy* / Q000208:ethnology*; D008875:Middle Aged; D016896:Treatment Outcome; D044465:White People
D000959:Antihypertensive Agents; D017311:Amlodipine; D017706:Lisinopril; D017292:Doxazosin; D002752:Chlorthalidone