Comparative effectiveness of angiotensin-converting enzyme inhibitors versus beta-blockers as second-line therapy for hypertension.
BACKGROUND
Trials comparing hypertension monotherapies have found either no difference or modest differences in blood pressure (BP) and cardiovascular events. However, no trial has assessed the comparative effectiveness of 2nd-line therapy in patients whose BP was not controlled with a thiazide diuretic.


RESULTS
This was an observational study conducted with a hypertension registry of adults enrolled in 3 large integrated health care delivery systems from 2002 to 2007. Patients newly started on thiazide monotherapy whose BP remained uncontrolled were observed after addition of either an angiotensin-converting enzyme (ACE) inhibitor or β-blocker for subsequent BP control and cardiovascular events. Patients for whom either add-on drug was indicated or contraindicated were excluded. After adjustment for patient characteristics and study year, BP control during the subsequent 6 to 18 months was comparable for the 2 agents (70.5% ACE, 69.0% β-blockers; P=0.09). Rates of incident myocardial infarction (hazard ratio, 1.05; 95% confidence interval, 0.69 to 1.58) and stroke (hazard ratio, 1.01; 95% confidence interval, 0.68 to 1.52) were also similar for the ACE inhibitor and β-blocker groups during an average of 2.3 years of follow-up. There were also no differences in heart failure or renal function.


CONCLUSIONS
ACE inhibitors and β-blockers are equally effective in lowering BP and preventing cardiovascular events for patients whose BP is not controlled with a thiazide diuretic alone and who have no compelling indication for a specific 2nd-line agent.
Magid
David J
DJ
Institute for Health Research, Kaiser Permanente Colorado, University of Colorado, 10065 E Harvard Ave., Denver, CO 80231, USA. David.J.Magid@kp.org
Shetterly
Susan M
SM
Margolis
Karen L
KL
Tavel
Heather M
HM
O'Connor
Patrick J
PJ
Selby
Joe V
JV
Ho
P Michael
PM
D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage* / Q000009:adverse effects; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D000959:Antihypertensive Agents / Q000008:administration & dosage* / Q000009:adverse effects; D004351:Drug Resistance; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D008297:Male; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D049993:Sodium Chloride Symporter Inhibitors / Q000627:therapeutic use
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D049993:Sodium Chloride Symporter Inhibitors