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CARDIOLOGY

LEGEND-HTN: Class 5 antihypertensive drugs, who is the “defective” in blood pressure?

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The current guidelines recommend thiazide diuretics, angiotensin receptor blockers (ARB), angiotensin converting enzyme inhibitors (ACEI), dihydropyridine calcium antagonists and non-combination in the absence of comorbidities.Dihydropyridine calcium antagonists are first-line treatments for hypertension.However, the best single-drug treatment for antihypertensive drugs is still unknown.Recently, the LEGEND-HTN test published in The Lancet shows that different types of antihypertensive drugs are equivalent in monotherapy, but thiazide diuretics are superior to ACEI, non-dihydropyridines.Calcium antagonists are even less effective than the other four classes of drugs.Dr. George Hripcsak (researcher) from Columbia University pointed out that the study largely confirmed the recommendation in the current US guidelines for first-line treatment of hypertension, that is, the efficacy of these five types of antihypertensive drugs is comparable.Studies have found that thiazide diuretics are more effective and safer than ACEI inhibitors.This is an important finding given the large number of patients who use ACEI.In addition, studies have found that non-dihydropyridine calcium antagonists are less safe and effective than other drugs, which is also expected.Real-world evidence Dr. Marc A. Suchard of the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues analyzed data from 4,893,391 patients from six administrative compensation databases and three electronic health databases.These data were used to generate 22,000 efficacy estimates to assess 55 outcomes in 9 databases.In the study, patients who received monotherapy with one of five classes of antihypertensive drugs (as defined in the 2017 AHA/ACC guidelines) were defined as new users, including thiazide diuretics (in the first antihypertensive treatment).17%), ARB (15%), ACEI (48%), dihydropyridine calcium antagonist (16%) and non-dihydropyridine calcium antagonist (3%).The three primary endpoints of the study were hospitalization for heart failure, acute myocardial infarction, and stroke.In addition, there were 6 secondary efficacy outcomes and 46 safety outcomes in the study.The results of the study showed that there was no significant difference between the different drug classes in more than half of the comparisons.Despite this, compared with ACEI, the risk of hospitalization for heart failure (HR=0.83, 95% CI: 0.74-0.95) and acute myocardial infarction (HR=0.84, 95% CI: 0.75) when treated with thiazide diuretics-0.95) and stroke (HR=0.83, 95% CI: 0.74-0.95) risk was significantly reduced.In terms of safety, thiazide diuretics are also better than ACEI.Non-dihydropyridine calcium channel blockers are clearly at a disadvantage compared to the other four classes of drugs.(A) Meta-analysis risk assessment of 9 outcomes with a primary outcome of orange and a secondary outcome of blue; (B) Assessment of cardiovascular events risk by database and meta-analysis.The color represents the database.At the top is the administrative compensation database, with the electronic health database in the middle and black representing all meta-analyses from other sources.Not all databases contain enough new users to be included in the study.Cardiovascular events were composite outcomes of acute myocardial infarction, hospitalization for heart failure, stroke, and sudden cardiac death.THZ: thiazide diuretic; ACEI: angiotensin converting enzyme inhibitor; ARB: angiotensin receptor antagonist; dCCB: dihydropyridine calcium antagonist; ndCCB: non-dihydropyridine calcium antagonist.
Dr. Hripcsak believes that the findings related to diuretics and ACEI in this study should be taken seriously.There may be differences in the efficacy of these two drugs, or there may be differences in the use of these two drugs.For example, assuming that an ACEI user stops taking the drug due to a number of side effects of ACEI, it may result in an overall difference in efficacy.In the accompanying commentary, Dr. Christopher W. Ives and Dr. Suzanne Oparil from the University of Alabama at Birmingham pointed out that the study provides a unique approach that can be used to analyze large-scale health data in the real world.In the future, the use of this unique analytical approach in large-scale observational trials may lead to new insights and clarify many unanswerable questions to enable clinicians to obtain better evidence-based medicine practices. , please do not reprint without the authorization of the copyright owner.

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