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Randomized Controlled Trial
. 2014 Jul;32(7):1503-13; discussion 1513.
doi: 10.1097/HJH.0000000000000204.

Blood pressure control and cardiovascular outcomes in normal-weight, overweight, and obese hypertensive patients treated with three different antihypertensives in ALLHAT

Efrain Reisin  1 , John W Graves, José-Miguel Yamal, Joshua I Barzilay, Sara L Pressel, Paula T Einhorn, Richard A Dart, Tamrat M Retta, Mohammad G Saklayen, Barry R Davis; ALLHAT Collaborative Research Group
Affiliations
Randomized Controlled Trial

Blood pressure control and cardiovascular outcomes in normal-weight, overweight, and obese hypertensive patients treated with three different antihypertensives in ALLHAT

Efrain Reisin et al. J Hypertens. 2014 Jul.

Abstract

Objective: Epidemiologically, there is a strong relationship between BMI and blood pressure (BP) levels. We prospectively examined randomization to first-step chlorthalidone, a thiazide-type diuretic; amlodipine, a calcium-channel blocker; and lisinopril, an angiotensin-converting enzyme inhibitor, on BP control and cardiovascular outcomes in a hypertensive cohort stratified by baseline BMI [kg/m(2); normal weight (BMI <25), overweight (BMI = 25-29.9), and obese (BMI >30)].

Methods: In a randomized, double-blind, practice-based Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, 33,357 hypertensive participants, aged at least 55 years, were followed for an average of 4.9 years, for a primary outcome of fatal coronary heart disease or nonfatal myocardial infarction, and secondary outcomes of stroke, heart failure, combined cardiovascular disease, mortality, and renal failure.

Results: Of participants, 37.9% were overweight and 42.1% were obese at randomization. For each medication, BP control (<140/90 mmHg) was equivalent in each BMI stratum. At the fifth year, 66.1, 66.5, and 65.1% of normal-weight, overweight, and obese participants, respectively, were controlled. Those randomized to chlorthalidone had highest BP control (67.2, 68.3, and 68.4%, respectively) and to lisinopril the lowest (60.4, 63.2, and 59.6%, respectively) in each BMI stratum. A significant interaction (P = 0.004) suggests a lower coronary heart disease risk in the obese for lisinopril versus chlorthalidone (hazard ratio 0.85, 95% confidence interval 0.74-0.98) and a significant interaction (P = 0.011) suggests a higher risk of end-stage renal disease for amlodipine versus chlorthalidone in obese participants (hazard ratio 1.49, 95% confidence interval 1.06-2.08). However, these results were not consistent among other outcomes.

Conclusion: BMI status does not modify the effects of antihypertensive medications on BP control or cardiovascular disease outcomes.

Trial registration: ClinicalTrials.gov NCT00000542.

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Conflict of interest statement

Conflicts of interest

Drs. Reisin, Graves, Yamal, Barzilay, Einhorn, Dart, Retta, and Saklayen, and Ms. Pressel have no conflicts to report. Dr. Davis has received honoraria from Takeda and Amgen.

Figures

Figure 1
Figure 1
Randomization and follow-up of ALLHAT participants by BMI group Abbreviations: A, amlodipine; C, chlorthalidone; L, lisinopril
Figure 2
Figure 2
Box-and-whisker plots of systolic and diastolic blood pressure at baseline and follow-up by BMI group. To make the graph more interpretable, the plotted data was Winsorized at the upper and lowest 1% of the distribution, where extreme values below or above the 1st and 99th percentiles were set equal to the 1st and 99th percentiles, respectively
Figure 3
Figure 3
Box-and-whisker plots of systolic blood pressure at baseline and follow-up by BMI and treatment group
Figure 4
Figure 4
Box-and-whisker plots of diastolic blood pressure at baseline and follow-up by BMI and treatment group
Figure 5
Figure 5
Bar plots of blood pressure control by BMI and treatment group
Figure 6
Figure 6
Hazard ratios for comparisons of amlodipine versus chlorthalidone in normal-weight, overweight, and obese participants, adjusted for age, male sex, black race, diabetes history, and current smoker
Figure 7
Figure 7
Hazard ratios for comparisons of lisinopril versus chlorthalidone in normal-weight, overweight, and obese participants, adjusted for age, male sex, black race, diabetes history, and current smoker
See this image and copyright information in PMC

Comment in

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