Treatment of Uncomplicated Hypertension: Are ACE Inhibitors and Calcium Channel Blockers as Effective as Diuretics and β-Blockers?

Article Figures & Data

Table 1.

Blood Pressure Lowering in Large-scale Clinical Trials Comparing Newer with Older Antihypertensive Agents.

Clinical Trial	Treatment Groups	Mean Baseline BP (mm Hg)	Mean BP Reduction (mm Hg)	Persistence (% on Randomized Drug at End of Study)	Tolerability (% Withdrawn Because of Adverse Effects)
CAPPP9,15	Captopril (n = 5,492)	161.8/99.8	11/8^*	Not reported	Not reported
	Diuretics/β-blockers (n = 5,493)	159.6 /98.1	11/8^*	Not reported	Not reported
STOP-210	Felodipine/Isradipine (n =2,196)		34.5 /17.5^*	66.2	Not reported
	Enalapril/Lisinopril (n = 2,205)	194/98^*	34.5 /16.2^*	61.3	Not reported
	Diuretics/β-blockers (n = 2,213)		34.8/16.6^*	62.3	Not reported
INSIGHT11	Nifedipine (n =3,157)	173/99^*	35/17^*	69.0	23.0
	Hydrochlorothiazide/amiloride(n = 3,164)	173/99^*	35/17^*	72.0	16.4
NORDIL12	Diltiazem (n = 5,410)	173.5/105.8	20.3 /18.7^†	77.0	Not reported
	Diuretics/β-blockers (n = 5,471)	173.4 /105.7	23.3/18.7^†	93.0	Not reported

Table 2.

Clinical Trials Evaluating Angiotensin-Converting Enzyme Inhibitors Compared with Diuretic or β-Blocker.

Study Endpoints	CAPPP⁹ RR (95% CI)^*	STOP-2¹⁰ RR (95% CI)^*
Combined primary endpoint
Fatal and nonfatal myocardial infarction and stroke, or other cardiovascular deaths	1.05 (0.90–1.22)
Fatal myocardial infarction, fatal stroke, or other fatal cardiovascular disease		1.01 (0.84–1.22)
Other endpoints
Fatal and nonfatal myocardial infarction	0.96 (0.77–1.19)	0.90 (0.72–1.13)
Fatal and nonfatal stroke	1.25^†(1.01–1.55)	0.90 (0.74–1.08)
All major cardiovascular events	0.94 (0.83–1.06)	0.94 (0.82–1.07)
Cardiovascular mortality	0.77 (0.57–1.04)	1.01 (0.84–1.22)
Total morbidity	0.93 (0.76–1.14)	1.02 (0.89–1.18)

Table 3.

Clinical Trials Evaluating Calcium Channel Blockers Compared with Diuretic or β-Blocker.

Study Endpoints	STOP-210 RR (95% CI)^*	INSIGHT11 RR (95% CI)^*	NORDIL12 RR (95% CI)^*
Combined primary endpoint
Fatal myocardial infarction, fatal stroke, or other fatal cardiovascular disease	0.97 (0.80–1.17)
Death from any cardiovascular or cerebrovascular cause; or nonfatal myocardial infarction, stroke, or heart failure		1.10 (0.91–1.34)
Fatal and nonfatal stroke, fatal and nonfatal stroke myocardial infarction, or other cardiovascular death			1.00 (0.87–1.15)
Other endpoints
Myocardial infarction	Fatal and nonfatal: 1.18 (0.95–1.47)	Fatal: 3.22^† (1.18–8.80) Nonfatal: 1.09 (0.76–1.58)	Fatal: 1.10 (0.64–1.88) Fatal and nonfatal: 1.16 (0.94–1.44)
Stroke	Fatal and nonfatal: 0.88 (0.73–1.06)	Fatal: 1.09 (0.48–2.48) Nonfatal: 0.87 (0.61–1.26)	Fatal: 0.96 (0.52–1.74) Fatal and nonfatal: 0.8 (0.65–0.99)
All major cardiovascular events	0.99 (0.87–1.12)	1.11 (0.90–1.36)	1.04 (0.91–1.18)
Cardiovascular mortality	0.97 (0.80–1.17)	1.16 (0.80–1.69)	1.11 (0.87–1.43)
Total mortality	0.99 (0.86–1.15)	1.01 (0.80–1.27)	1.00 (0.83–1.20)

Table 4.

Monthly Cost of Selected Antihypertensive Agents.

Drug	Usual Dose	Cost per Month^* ($)
Hydrochlorothiazide (generic)	25 mg qd	2.40
Atenolol (generic)	50 mg qd	2.40
Metoprolol tartrate (generic)	50 mg bid	9.56
Captopril (generic)	25 mg bid	8.42
Enalapril maleate (generic)	10 mg qd	17.67
Lisinopril (Prinivil, Zestril)^†	10 mg qd	27.94
Nifedipine CR (generic)	60 mg qd	27.25
Diltiazem CD (generic)	180 mg qd	23.42
Verapamil CR tablet (generic)	180 mg qd	7.00
Amlodipine (Norvasc)	5 mg qd	39.82

Note: qd = every day, bid − twice a day.
* From drugstore.com (available at: http://www.drugstore.com). Calculated based on a 90- to 100-tablet purchase.
† Generic lisinopril (Prinivil only) approved, but not yet available.