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Original Contribution
December 18, 2002

Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)

Author Affiliations

ALLHAT Authors/Officers and Coordinators: Curt D. Furberg, MD, PhD; Jackson T. Wright, Jr, MD, PhD; Barry R. Davis, MD, PhD; Jeffrey A. Cutler, MD, MPH; Michael Alderman, MD; Henry Black, MD; William Cushman, MD; Richard Grimm, MD, PhD; L. Julian Haywood, MD; Frans Leenen, MD; Suzanne Oparil, MD; Jeffrey Probstfield, MD; Paul Whelton, MD, MSc; Chuke Nwachuku, MA, MPH; David Gordon, MD, PhD; Michael Proschan, PhD; Paula Einhorn, MD, MS; Charles E. Ford, PhD; Linda B. Piller, MD, MPH; J. Kay Dunn, PhD; David Goff, MD, PhD; Sara Pressel, MS; Judy Bettencourt, MPH; Barbara deLeon, BA; Lara M. Simpson, MS; Joe Blanton, MS; Therese Geraci, MSN, RN, CS; Sandra M. Walsh, RN; Christine Nelson, RN, BSN; Mahboob Rahman, MD; Anne Juratovac, RN; Robert Pospisil, RN; Lillian Carroll, RN; Sheila Sullivan, BA; Jeanne Russo, BSN; Gail Barone, RN; Rudy Christian, MPH; Sharon Feldman, MPH; Tracy Lucente, MPH; David Calhoun, MD; Kim Jenkins, MPH; Peggy McDowell, RN; Janice Johnson, BS; Connie Kingry, RN, BSN; Juan Alzate, MD; Karen L. Margolis, MD; Leslie Ann Holland-Klemme, BA; Brenda Jaeger; Jeffrey Williamson, MD, MHS; Gail Louis, RN; Pamela Ragusa, RN, BSN; Angela Williard, RN, BSN; R. L. Sue Ferguson, RN; Joanna Tanner; John Eckfeldt, MD, PhD; Richard Crow, MD; John Pelosi, RPh, MS.

JAMA. 2002;288(23):2981-2997. doi:10.1001/jama.288.23.2981

Context Antihypertensive therapy is well established to reduce hypertension-related morbidity and mortality, but the optimal first-step therapy is unknown.

Objective To determine whether treatment with a calcium channel blocker or an angiotensin-converting enzyme inhibitor lowers the incidence of coronary heart disease (CHD) or other cardiovascular disease (CVD) events vs treatment with a diuretic.

Design The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind, active-controlled clinical trial conducted from February 1994 through March 2002.

Setting and Participants A total of 33 357 participants aged 55 years or older with hypertension and at least 1 other CHD risk factor from 623 North American centers.

Interventions Participants were randomly assigned to receive chlorthalidone, 12.5 to 25 mg/d (n = 15 255); amlodipine, 2.5 to 10 mg/d (n = 9048); or lisinopril, 10 to 40 mg/d (n = 9054) for planned follow-up of approximately 4 to 8 years.

Main Outcome Measures The primary outcome was combined fatal CHD or nonfatal myocardial infarction, analyzed by intent-to-treat. Secondary outcomes were all-cause mortality, stroke, combined CHD (primary outcome, coronary revascularization, or angina with hospitalization), and combined CVD (combined CHD, stroke, treated angina without hospitalization, heart failure [HF], and peripheral arterial disease).

Results Mean follow-up was 4.9 years. The primary outcome occurred in 2956 participants, with no difference between treatments. Compared with chlorthalidone (6-year rate, 11.5%), the relative risks (RRs) were 0.98 (95% CI, 0.90-1.07) for amlodipine (6-year rate, 11.3%) and 0.99 (95% CI, 0.91-1.08) for lisinopril (6-year rate, 11.4%). Likewise, all-cause mortality did not differ between groups. Five-year systolic blood pressures were significantly higher in the amlodipine (0.8 mm Hg, P = .03) and lisinopril (2 mm Hg, P<.001) groups compared with chlorthalidone, and 5-year diastolic blood pressure was significantly lower with amlodipine (0.8 mm Hg, P<.001). For amlodipine vs chlorthalidone, secondary outcomes were similar except for a higher 6-year rate of HF with amlodipine (10.2% vs 7.7%; RR, 1.38; 95% CI, 1.25-1.52). For lisinopril vs chlorthalidone, lisinopril had higher 6-year rates of combined CVD (33.3% vs 30.9%; RR, 1.10; 95% CI, 1.05-1.16); stroke (6.3% vs 5.6%; RR, 1.15; 95% CI, 1.02-1.30); and HF (8.7% vs 7.7%; RR, 1.19; 95% CI, 1.07-1.31).

Conclusion Thiazide-type diuretics are superior in preventing 1 or more major forms of CVD and are less expensive. They should be preferred for first-step antihypertensive therapy.