Blood Pressure Medication for People with Metabolic Syndrome

For people with metabolic syndrome—who are at increased risk for cardiovascular diseases like heart attack, heart failure and stroke—treatment of high blood pressure with less expensive diuretic drugs may be a better choice than newer, more costly medications, according to a new report.

People with metabolic syndrome have 3 or more risk factors for heart disease, including elevated blood pressure, low HDL (good cholesterol) levels and diabetes or pre-diabetes. Healthy lifestyle changes—weight loss, increased physical activity, an improved diet and quitting smoking—are the first line of treatment. Medicines may be needed to control individual risk factors such as high blood pressure.

Many doctors currently prescribe alpha-blockers, calcium channel blockers and ACE-inhibitors for controlling blood pressure in patients with metabolic syndrome. These medications are sometimes favored because of their short-term effects on blood sugar and cholesterol levels. But improvements in these measurements don’t necessarily translate into better prevention of cardiovascular disease than an older class of medication called diuretics.

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, or ALLHAT, was sponsored by NIH’s National Heart, Lung and Blood Institute (NHLBI) to compare a diuretic (chlorthalidone) with the 3 newer classes of medications used to treat high blood pressure. The study involved 42,418 participants, ages 55 and older, with high blood pressure and at least 1 other risk factor for heart disease. Of those, 23,077 had metabolic syndrome with diabetes or pre-diabetes at the time of enrollment. Roughly 35% of the study’s participants were black.

The ALLHAT researchers reported in 2002 that, overall, diuretics were the most beneficial of the drug classes for treating high blood pressure and protecting against cardiovascular disease. The latest analysis, published in the January 28, 2008, issue of Archives of Internal Medicine, focused on people with metabolic syndrome. It showed that, for both men and women, the diuretic-based treatment was more protective against heart failure and overall cardiovascular disease than the ACE-inhibitor (lisinopril) and alpha-blocker (doxazosin)-based treatments. The diuretic-based treatment was also more protective against heart failure than the calcium channel blocker (amlodipine) one. The results applied to both black and non-black participants.

The results provided particularly important evidence for black patients with metabolic syndrome. When compared with those taking diuretics, those receiving ACE-inhibitors had poorer blood pressure control and a 24% greater risk of overall cardiovascular disease. They also had a 70% greater risk of kidney failure.

“The ALLHAT study has been remarkably consistent in showing that the lower-cost diuretic is superior to newer blood pressure medications for the prevention of cardiovascular disease,” said Dr. Paula Einhorn of NHLBI’s Division of Prevention and Population Sciences.