4 VIEWS & REVIEWS

Beta blockers and diuretics still win out in hypertension

Concern over the reported adverse atherogenic effects of beta blockers and diuretics, and intensive marketing of newer classes of antihypertensives without these effects, have combined to reduce the use of the older agents in patients with hypertension. However, Dr Swales of the Leicester Royal Infirmary, UK., does not I • •• ,U tilly muOll to modify tIN Britilll Hypertell,ioll Society pilklilUl tlult di"retic, tl1Id betll bloc,"n ,/Io"ltI be tile /int-liu IIgat" .

Small increases in total, LDL and VLDL cholesterol levels have been observed with diuretic therapy, while beta blockers tend to increase triglyceride levels and decrease HDL cholesterol levels. These changes could account for the disappointing impact of antihypertensive therapy on the incidence of ischaemic heart disease, although trials to compare diuretics and beta blockers with the newer antihypertensive agents are needed to fully assess this effect.

With the current evidence being inadequate, cost differences must be considered when treatment is chosen. ACE inhibitors are 50 times more expensive than beta blockers and diuretics. Therapy is often long term, compounding the cost difference. Also, it is now known that the observed lipid variations affect coronary risk to the same extent as natural lipid abnormalities and the older agents do reduce the risk of stroke. Interestingly, most strokes occurring in patients with hypertension are atherothrombotic rather than haemorrhagic. .

As patients requiring antihypertensives often have ischaemic heart disease, Dr Swales prefers beta blockers to diuretics. Beta blockers are known to prevent secondary infarction; they have also been suggested, in some trials, to beneficially affect coronary risk. Swales JO. Antihypenensive drugs and plasma lipids. British Hean Journal 66: 409-410. Dec 1991 19"

18 Jan 1992 INPHARMAe ISSN 0156-2703/92/0118-0004/0$01.00/0 C Adis Inllmaliallal lid