When I was a (relatively) young resident training in Internal Medicine, we, the hotshot residents in an elite medical school, used to indulgingly sneer at our attending physicians when they would recommend some passé treatment, like the quaint diuretics (for heaven’s sake!) for hypertension. Haven’t they heard of ACE inhibitors, or calcium channel inhibitors, or at the very least an old-fashioned beta blocker? In fact, today’s hypertensives, especially those who also have metabolic syndrome, are a walking pharmacopea—they take all of the above. Now, I am not arguing here that the other drug groups should not be used in the management of hypertension, especially the ones refractive to diuretics. But a study in the latest Archives of Internal Medicine elicited old images and memories of my old profs, smiling benignly at our quotes, with almost religious reverence, from the latest article published in the New England Journal of Medicine. The study was called “Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial” or ALLHAT. Do they invent those names to fit a catchy acronym?
The new research shows that in people with high blood pressure as part of metabolic syndrome, a cluster of conditions that increases the risk for heart disease, diuretics offer greater protection against cardiovascular disease, including heart failure, and are at least as effective for lowering blood pressure as newer, more expensive medications. The findings run counter to current medical practices that favor ACE-inhibitors, alpha-blockers, and calcium channel blockers for treatment of high blood pressure in those with metabolic syndrome. In addition, the results provide important new evidence supporting the use of diuretics for initial blood pressure-lowering therapy in black patients with metabolic syndrome.
The ALLHAT study was a randomized, double-blind trial involving 42,418 participants, ages 55 and older with high blood pressure (140/90 mm Hg or greater) and at least one other risk factor for heart disease. Of those, 23,077 had metabolic syndrome with diabetes or pre-diabetes (fasting blood glucose of 100 mg/dL or greater) at the time of enrollment. Roughly 35% of the participants were black.
In both black and non-black study participants with metabolic syndrome, the diuretic-based treatment was more protective against heart failure and also against overall cardiovascular disease (coronary heart disease, stroke, heart failure, or peripheral arterial disease combined) when compared with the ACE-inhibitor and alpha-blocker-based treatments. Compared with the calcium channel blocker-based treatment, the diuretic-based treatment was more protective against heart failure.
When compared with those taking diuretics, black participants with metabolic syndrome receiving ACE-inhibitors had poorer blood pressure control and a 24% greater risk of overall cardiovascular disease. This included a 19% greater risk of coronary heart disease, a 37% greater risk of stroke, and a 49% greater risk of heart failure. They also had a 70% greater risk of kidney failure.
Why do we ignore the old standbys?
I don’t think there is a simple answer. Patients always want the latest medicine, equating “latest” with “best”, and “old” with the dark ages of medicine. There is also the relentless promotion foisted on physicians by drug companies.
But academic marketing studies suggest another reason: Diuretics are dirt cheap, and low cost is suggestive of low quality. Raise the price of an item and the assumption is that you are selling something superior. If you are a consultant, I’ll let you in on a little secret. When I left academic life, I started a small consulting business. The response was gratifyingly positive, and soon enough I was running out of room for more clients. Rather than refuse new clients, I decided to use market forces: Simply raise my fees to price myself out of the market.
To my astonishment, that only caused an increase in the number of clients. Why? Simple: If this guy charges so much, he must be good. The individual on the other end of the phone was not putting his own money down, “only” the company’s money. Makes the decision to hire this expensive hotshot a lot easier.
I suspect that one of the reasons it is so easy for a person to expect the newest and the most expensive, and for the physician to oblige, is that neither puts his own money into the game.
I’ll leave the solution to this dilemma to the policy wonks among us.