Right now, there’s a real lack of research aimed at helping doctors choose which drug class a patient should start on, Hripcsak believes.
He noted that the current literature has data from randomized, controlled clinical trials that included a total of just 31,000 patients, and none of those patients were just beginning treatment for high blood pressure.
“Randomized clinical trials demonstrate a drug’s effectiveness and safety in a highly defined patient population,” Hripcsak explained in a university news release. “But they’re not good at making comparisons among multiple drug classes in a diverse group of patients that you would encounter in the real world.”
With the new study, Hripcsak believes that “we have found a way to fill in the gaps left by randomized, controlled trials.
Two cardiologists who weren’t involved in the new study took different stances on the results — suggesting that debate on this topic is far from over.
Dr. Satjit Bhusri said the study “is statistically very powerful and can have profound changes in medical practice.” But he added that decisions around which anti-hypertensive drug to choose should still be made on a case-by-case basis.
“I would suggest that the choice of first-line blood pressure therapy be specific to the patient, especially in those with heart disease or at an elevated risk of heart disease.,” Bhusri advised. But, for patients “treated for high blood pressure without an elevated cardiac risk, thiazide medication should be the first-line [choice],” he said.
However, cardiologist Dr. Benjamin Hirsh took issue with the Columbia study’s methodology.
The researchers’ conclusion that “use of thiazide diuretics over ACE inhibitors causes ‘15% fewer cardiovascular effects’ is a conclusion that is highly subject to bias,” he noted.
“ACE Inhibitors are used to treat patients with higher cardiovascular risk, such as those with advanced heart failure and kidney disease,” Hirsh explained.”So, these patients are at higher risk for heart disease in general.”
According to Hirsh, it stands to reason that patients on ACE inhibitors would have worse outcomes than those on thiazide diuretics, because they were sicker to begin with.
And he noted that “thiazide diuretics also must be used carefully with other drugs.” Those include newer diabetes medications such as Jardiance, because the concurrent use of a thiazide diuretic might trigger too-low blood pressure, Hirsh explained.