Comparative Efficacy of Antihypertensive Drug Classes – A Systematic Review and Network Meta-analyses (Review)
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Abstract
Multiple systematic reviews have demonstrated no significant differences between blood pressure (BP)-lowering drug classes on protection against major cardiovascular events. However, there is a paucity of similar data on the comparative efficacy of different antihypertensive drug classes on BP lowering. Published randomized controlled trials were reviewed from MEDLINE, EMBASE, Web of Science, and Cochrane for trials. We included randomized controlled trials of antihypertensive agents, with at least 100 participants and with a minimum follow-up of 1-year. Two authors independently selected the included trials, evaluated the risk of bias, and retrieved the data on BP response. Meta-analyses were performed to summarize the pooled standardized mean differences (SMD) of BP between treatment arms. Anetwork meta-analysis was also completed to compare the BP response of all possible pairs of antihypertensive agents (classes of drugs). We identified 66 trials, with 163,491 participants. Calcium channel blockers (CCBs) were superior to angiotensinconverting enzyme inhibitors (ACEIs) in lowering systolic BP (pooled SMD of −0.09 mmHg, P = 0.006, high quality based on Grading of Recommendations, Assessment, Development and Evaluation) and diastolic BP (−0.15 mmHg, P = 0.0002, high quality). Diuretics (DIs) were superior to ACEIs (−0.11 mmHg, P < 0.00001, moderate quality) and CCB (−0.10 mmHg, P = 0.0001, moderate quality) in lowering systolic BP. Network meta-analysis involving 94 pairwise comparisons showed DIs lowered BP greater than any other antihypertensive agents except angiotensin II receptor blockers which had a similar effect.
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References
Bhatnagar P, Wickramasinghe K, Williams J, Rayner M, Townsend N. The epidemiology of cardiovascular disease in the UK 2014. Heart 2015;101:1182-9.
World Health Organization. Causes of Death 2008. Geneva: World Health Organization; 2008.
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: Analysis of worldwide data. Lancet 2005;365:217-23.
Gupta R, Guptha S. Strategies for initial management of hypertension. Indian J Med Res 2010;132:531-42.
Neal B, MacMahon S, Chapman N. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: Results of prospectively designed overviews of randomised trials. Blood pressure lowering treatment trialists’ collaboration. Lancet 2000;356:1955-64.
Centers for Disease Control and Prevention (CDC). Vital signs: Awareness and treatment of uncontrolled hypertension among adults--United States, 2003-2010. MMWR Morb Mortal Wkly Rep 2012;61:703-9.
Bundy JD, Li C, Stuchlik P, Bu X, Kelly TN, Mills KT, et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: A systematic review and network metaanalysis. JAMA Cardiol 2017;2:775-81.
Andrade SE, Gurwitz JH, Field TS, Kelleher M, Majumdar SR, Reed G, et al. Hypertension management: The care gap between clinical guidelines and clinical practice. Am J Manag Care 2004;10 7 Pt 2:481-6.
Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressurelowering treatment on cardiovascular outcomes and mortality: 14 effects of different classes of antihypertensive drugs in older and younger patients: Overview and meta-analysis. J Hypertens 2018;36:1637-47.
Blood Pressure Lowering Treatment Trialists’ Collaboration. Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: An individual participant-level data meta-analysis. Lancet 2021;397:1625-36.
Abel N, Contino K, Jain N, Grewal N, Grand E, Hagans I, et al. Eighth joint national committee (JNC-8) guidelines and the outpatient management of hypertension in the AfricanAmerican population. North Am J Med Sci 2015;7:438-45.
Williams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The task force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018;36:1953-2041.
Marathe PH, Gao HX, Close KL. american diabetes association standards of medical care in diabetes 2017. J Diabetes 2017;9:320-4.
Whitworth JA, Chalmers J. World health organisationinternational society of hypertension (WHO/ISH) hypertension guidelines. Clin Exp Hypertens 2004;26:747-52.
Packer M. Are meta-analyses a form of medical fake news? Thoughts about how they should contribute to medical science and practice. Circulation 2017;136:2097-9.
Strandberg TE, Pitkala K. What is the most important component of blood pressure: Systolic, diastolic or pulse pressure? Curr Opin Nephrol Hypertens 2003;12:293-7.
Mancia G, Seravalle G, Grassi G. Systolic blood pressure: An underestimated cardiovascular risk factor. J Hypertens Suppl 2002;20:S21-7.
Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Agespecific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903-13.
Wu HY, Huang JW, Lin HJ, Liao WC, Peng YS, Hung KY, et al. Comparative effectiveness of renin-angiotensin system blockers and other antihypertensive drugs in patients with diabetes: Systematic review and bayesian network meta-analysis. BMJ 2013;347:f6008.
Xie X, Liu Y, Perkovic V, Li X, Ninomiya T, Hou W, et al. Reninangiotensin system inhibitors and kidney and cardiovascular outcomes in patients with CKD: A bayesian network metaanalysis of randomized clinical trials. Am J Kidney Dis 2016;67:728-41.
Wright JM, Lee CH, Chambers GK. Systematic review of antihypertensive therapies: Does the evidence assist in choosing a first-line drug? CMAJ 1999;161:25-32.
Wright JM. Choosing a first-line drug in the management of elevated blood pressure: What is the evidence? 3: Angiotensin-converting-enzyme inhibitors. CMAJ 2000;163:293-6.