ABSTRACT
The way in which the blood pressure is lowered may make a difference. This issue has recently been debated (8-10). The PROGRESS trial (11) showed that among patients with previous stroke or transient ischemic attack (TIA), those randomized to perindopril and indapamide had significantly better outcomes than those randomized to placebo. This, taken with the stroke prevention results of the HOPE trial (12), suggested that perhaps treatment with angiotensin-converting enzyme inhibitors (ACEi) may be more effective than other treatments. The possibility that blockade of the rennin-angiotensin system may be the mechanism was supported by the findings of the LIFE trial, which showed that patients randomized to losartan had significantly better outcomes, with about a 25% relative risk reduction for stroke, compared with patients randomized to atenolol, despite identical blood pressure control (13). The Study on Cognition and Prognosis in the Elderly (SCOPE) also showed a significant reduction of non-fatal stroke with candesartan vs. alternative therapies (14). However, the ALLHAT trial reported superior results in patients randomized to diuretic (15). It is very important to recognize that these results were driven by a major reduction of stroke in African-American participants, who represented 35% of patients in ALLHAT; the opposite result was obtained in the Second Australian National Blood Pressure Study (ANBP2) (16), in which only 0.55% of patients were of African origin. This difference in results of treatment with diuretics vs. other classes of antihypertensive therapy raises the issue of low-renin hypertension.
