There are >70-million hypertensive individuals in the United States, and >45-million persons take antihypertensive medications.1,2 Despite the results of the Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT), other trials, and the recommendations in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, well under 50% of these regimens include a thiazide-type diuretic.2,3 In the Department of Veterans’ Affairs, which participated in several of the studies supporting the use of thiazide diuretics, ≈35% of hypertensive patients on pharmacotherapy had a thiazide diuretic included in their hypertension treatment regimens in 2003.4 In private patient encounters, thiazide diuretic use rose from 19% of all of the antihypertensive patient visits in 2002 to 26% in 2004.5The recommendations for preferred use of thiazide-type diuretics are based on >4 decades of clinical trials, including active-controlled trials, where diuretics were tested against other drugs for their efficacy in preventing hard clinical outcomes, such as myocardial infarction, death, stroke, heart failure, and renal failure. ALLHAT, a randomized, double-blind, active-controlled antihypertensive treatment trial in 42 418 patients assigned to a thiazide-type diuretic, an angiotensin-converting enzyme (ACE) inhibitor, a calcium channel-blocker, (average follow-up: 4.9 years), or the doxazosin/chlorthalidone comparison (terminated early, average follow-up: 3.2 years) showed that the diuretic was at least as beneficial as the comparator drugs in lowering blood pressure (BP) and preventing cardiovascular (CV) and renal outcomes and was superior for preventing heart failure (versus each comparator arm), combined CV events (versus α-blocker and ACE-inhibitor arms), and stroke (versus ACE inhibitor [black subjects only] and α-blocker).6 The ongoing success of thiazide-type diuretics in large, adequately powered hypertension outcome trials and new guidelines have created the basis for increased diuretic use.2,6However, clinical trials have also frequently shown potentially …
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