Treatment of hypertension in the elderly: III. response of isolated systolic hypertension to various doses of hydrochlorothiazide: results of a Department of Veterans Affairs Cooperative Study

Article Abstract:

When blood pressure is measured, two numbers are recorded, the systolic or top number, and the diastolic or bottom number. If either or both of these numbers is elevated above normal (140/90 is generally regarded as the upper limit of normal), then the patient is considered to have hypertension, or high blood pressure. Several studies have shown an increased incidence of cardiovascular disease with isolated systolic hypertension, in which only the top number is elevated. One recent study has shown that treatment of isolated systolic hypertension, or ISH, reduces the incidence of cardiac events. ISH has also been associated with a 2.5 times greater than normal risk of stroke. As part of a larger Department of Veterans Affairs study on the treatment of hypertension in the elderly, researchers assessed a group of 51 men with ISH who were over the age of 60. These patients were randomly assigned to receive the drug hydrochlorothiazide in either 25 or 50 milligram doses, once or twice a day. Nearly 60 percent of the patients in the lower-dose group reached the desired blood pressure with a single daily dose of hydrochlorothiazide, and over 60 percent of the men in the higher-dose group achieved their blood pressure goal with a single daily dose. A few patients from each group required twice-daily dosing, and only five patients required the addition of a second drug. One side effect of hydrochlorothiazide is a drop in the blood potassium level, and this was found to be more prevalent in the higher-dose group and the twice-daily 25 milligram group. Other side effects were minor, and no difference was found in their incidence among the higher- and lower-dose groups. The results of this study suggest that ISH is treatable in a significant number of cases with a low dose of hydrochlorothiazide that is associated with relatively few side effects. (Consumer Summary produced by Reliance Medical Information, Inc.)

Cardiovascular diseases, Prevention, Demographic aspects, Dosage and administration, Hydrochlorothiazide

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How bad are diuretic-induced hypokalemia and hypercholesterolemia?

Article Abstract:

One of the aims of reducing high blood pressure with antihypertensive drugs is to reduce the number of deaths from coronary heart disease (CHD). Although antihypertensives reduce hypertension, they do not, as originally hoped, reduce the mortality from CHD. Antihypertensive drugs such as thiazides which work by decreasing the blood volume may actually act to increase the risk of CHD. Thiazides cause hypokalemia, a reduction in potassium in the blood which can produce fatal irregular heart beats. In addition, thiazides are thought to increase cholesterol, which can worsen atherosclerosis, or the buildup of plaque inside blood vessels. The role of thiazides in producing hypokalemia and hypercholesterolemia is controversial. An editorial by Dr. E.D. Freis in the December 1989 issue of Archives of Internal Medicine defends the use of thiazides in the treatment of moderate hypertension. It is agreed that many thiazides studies uncovered overall reduction of mortality and strokes. Either diuretics or else beta blockers, another type of antihypertensive agent, should be used to treat hypertension. Neither of these agents has proved to lower the overall mortality from coronary heart disease. Deaths from coronary heart disease may instead be caused by the disease process itself and not the combined failure of these two drugs. Some researchers blame the overtreatment or undertreatment of patients for the inability to reduce CHD-related mortality. However, high cholesterol and low potassium levels produced by thiazides are problems among selected patients. Hypercholesterolemia (high cholesterol) produced by thiazides is not temporary and may actually persist, and hypokalemia itself can raise blood pressures. In addition, lower doses of thiazides may work better than Dr. Freis suggests. Thiazides will continue to be used but the dangers associated with their use are still of concern to the medical community.

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Critique of the clinical importance of diuretic-induced hypokalemia and elevated cholesterol level

Article Abstract:

One of the aims of reducing high blood pressure with antihypertensive drugs is to reduce the number of deaths from coronary heart disease (CHD). Although antihypertensives reduce hypertension, they do not, as originally hoped, reduce the mortality from CHD. The disappointing results of many drug trials may be explained by various hypotheses. Drugs either lower the blood pressures too far, are begun too late in patients with advanced atherosclerosis, or have no effect on risk factors such as poor diet and cigarette smoking. It is possible that the length of drug trial follow-ups may be too short to detect differences. Antihypertensive drugs such as thiazides, which work by decreasing the blood volume, may actually act to increase the risk of CHD. Thiazides cause hypokalemia, a reduction in potassium in the blood which can produce fatal irregular heart beats. In addition, thiazides are thought to increase cholesterol levels, which can worsen atherosclerosis, or the buildup of plaque inside blood vessels. A review of ongoing studies has not confirmed that thiazide diuretics increase the risk for CHD. The effect of thiazides on cholesterol is temporary and cholesterol levels usually return to normal a year after beginning treatment. Physicians who are either reducing doses of or discontinuing thiazides altogether are limiting the potential for therapeutic success by looking to other less effective and more expensive drugs. Thiazides may not be useful for all patients with high blood pressure, but there remains a large population of patients who will benefit greatly from their use. Therefore, thiazides used for the treatment of high blood pressure should not be eliminated.

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