Outcomes in Hypertensive Black and Nonblack Patients Treated with Chlorthalidone, Amlodipine, and Li

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Outcomes in Hypertensive Black and Nonblack
Patients Treated with Chlorthalidone, Amlodipine,
and LisinoprilWright JT, Dunn JK, Cutler JA et
al. JAMA 20052931595-1608.
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Randomized Design of ALLHAT BP Trial
42,418 High-risk hypertensive patients
Consent / Randomize
Amlodipine Chlorthalidone Doxazosin Lisinopril
Follow until death or end of study (4-8 years,
mean 4.9 years)
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Race Subgroup Analysis

• ALLHAT reported no differences in the primary CHD
  outcome, but overall superiority of thiazide-type
  diuretic for first-step therapy of hypertension
  based on differences in secondary outcomes
• The population of blacks with hypertension has
  the highest morbidity and mortality from
  hypertension of any population group in the U.S.
• Race was a prespecified subgroup for ALLHAT

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Baseline Characteristics by Race(Chlorthalidone,
Amlodipine, Lisinopril)
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Blood Pressure at 5 Yearsby Race
P lt 0.005 compared to Chlorthalidone
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BP Results by Treatment Group by Race
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on 3 Antihypertensive Drugs by Randomized
Group and Race at 5 Years
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BP Control (lt140/90 mm Hg) and Mean BP by
Randomized Group and Race at 5 Years
135/78
136/76
139/79
133/74
134/74
134/74
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Serum Potassium(mean mmol/l)by Treatment Group
and Race
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Serum Cholesterol(mean mg/dl)by Treatment Group
and Race
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Fasting Glucose(mean mg/dl)by Treatment Group
and Race
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Fasting Glucose ?126 mg/dlby Treatment Group and
Race
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Black vs. Non-Black Amlodipine/Chlorthalidone Rela
tive Risk and 95 Confidence Intervals
Non-Black
0.97 (0.87 - 1.08)
0.94 (0.87 - 1.03)

0.99 (0.92 - 1.07)
1.04 (0.97 - 1.10)
0.93 (0.79 - 1.10)
1.08 (0.79 - 1.48)
1.32 (1.17 - 1.49)
0.50
1
2
Favors Chlorthalidone
Favors Amlodipine
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Black vs. Non-Black Lisinopril/Chlorthalidone Rela
tive Risk and 95 Confidence Intervals
Black

Favors Chlorthalidone
Favors Lisinopril
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Heart Failure Rate for Blacks by Treatment Group
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ANGIOEDEMA
There were 3 cases (lt0.1) of angioedema in the
amlodipine group (comparison to chlorthalidone
not significant).
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Antihypertensive TrialImplications

• Diuretics should be the drug of choice for
  initial therapy of hypertension. The evidence
  for this recommendation is even stronger for
  Black hypertensive patients..
• For the patient who cannot take a diuretic (which
  should be an unusual circumstance), CCBs and
  ACEIs may be considered. However, in Black
  hypertensive patients, ACEIs should be
  considered second-line therapy.
• Most hypertensive patients require more than one
  drug. Diuretics should generally be part of the
  antihypertensive regimen. Lifestyle advice should
  also be provided.

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Extra Slides
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Blacks Amlodipine/Chlorthalidone Relative Risk
and 95 Confidence Intervals
0.50
1
2
Favors Amlodipine Favors
Chlorthalidone
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Blacks Lisinopril/Chlorthalidone Relative Risk
and 95 Confidence Interval
0.50
1
2
Favors Lisinopril Favors
Chlorthalidone
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Non-Blacks Amlodipine/Chlorthalidone Relative
Risk and 95 Confidence Intervals


2
0.50
1
Favors Amlodipine Favors
Chlorthalidone
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Non-Blacks Lisinopril/Chlorthalidone Relative
Risk and 95 Confidence Intervals


0.50 1 2
Favors Lisinopril Favors
Chlorthalidone