Blood pressure control and cardiovascular outcomes in normal-weight, overweight, and obese hypertensive patients treated with three different antihypertensives in ALLHAT.
OBJECTIVE
Epidemiologically, there is a strong relationship between BMI and blood pressure (BP) levels. We prospectively examined randomization to first-step chlorthalidone, a thiazide-type diuretic; amlodipine, a calcium-channel blocker; and lisinopril, an angiotensin-converting enzyme inhibitor, on BP control and cardiovascular outcomes in a hypertensive cohort stratified by baseline BMI [kg/m(2); normal weight (BMI <25), overweight (BMI = 25-29.9), and obese (BMI >30)].


METHODS
In a randomized, double-blind, practice-based Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, 33,357 hypertensive participants, aged at least 55 years, were followed for an average of 4.9 years, for a primary outcome of fatal coronary heart disease or nonfatal myocardial infarction, and secondary outcomes of stroke, heart failure, combined cardiovascular disease, mortality, and renal failure.


RESULTS
Of participants, 37.9% were overweight and 42.1% were obese at randomization. For each medication, BP control (<140/90 mmHg) was equivalent in each BMI stratum. At the fifth year, 66.1, 66.5, and 65.1% of normal-weight, overweight, and obese participants, respectively, were controlled. Those randomized to chlorthalidone had highest BP control (67.2, 68.3, and 68.4%, respectively) and to lisinopril the lowest (60.4, 63.2, and 59.6%, respectively) in each BMI stratum. A significant interaction (P = 0.004) suggests a lower coronary heart disease risk in the obese for lisinopril versus chlorthalidone (hazard ratio 0.85, 95% confidence interval 0.74-0.98) and a significant interaction (P = 0.011) suggests a higher risk of end-stage renal disease for amlodipine versus chlorthalidone in obese participants (hazard ratio 1.49, 95% confidence interval 1.06-2.08). However, these results were not consistent among other outcomes.


CONCLUSIONS
BMI status does not modify the effects of antihypertensive medications on BP control or cardiovascular disease outcomes.
aSection of Nephrology and Hypertension, Louisiana State University Health Science Center, New Orleans, Louisiana bDivision of Nephrology/Hypertension, Mayo Clinic, Rochester, Minnesota cCoordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas dDivision of Endocrinology, Kaiser Permanente of Georgia and Emory University School of Medicine, Atlanta, Georgia eThe National Heart, Lung, and Blood Institute, Bethesda, Maryland fCenter for Human Genetics, Marshfield Clinic Research Foundation, Marshfield, Wisconsin gHoward University Hypertension and Lipid Clinic, Howard University Hospital, Washington, District of Columbia hVeterans Affairs Medical Center and Wright State University Veterans Affairs Campus, Dayton, Ohio, USA.
Efrain
E
Reisin
John W
JW
Graves
José-Miguel
JM
Yamal
Joshua I
JI
Barzilay
Sara L
SL
Pressel
Paula T
PT
Einhorn
Richard A
RA
Dart
Tamrat M
TM
Retta
Mohammad G
MG
Saklayen
Barry R
BR
Davis
D000368:Aged; D000369:Aged, 80 and over; D017311:Amlodipine / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001794:Blood Pressure / Q000187:drug effects; D015992:Body Mass Index; D002121:Calcium Channel Blockers / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000517:prevention & control; D002752:Chlorthalidone / Q000627:therapeutic use; D015331:Cohort Studies; D004232:Diuretics / Q000627:therapeutic use; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications* / Q000188:drug therapy* / Q000503:physiopathology; D017706:Lisinopril / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications* / Q000473:pathology / Q000503:physiopathology; D050177:Overweight / Q000150:complications* / Q000473:pathology / Q000503:physiopathology; D011446:Prospective Studies
D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D002121:Calcium Channel Blockers; D004232:Diuretics; D017311:Amlodipine; D017706:Lisinopril; D002752:Chlorthalidone