Do I Need to Continue With Diuretics After a Heart Attack
New Study Says Diuretics Raise Heart Attack Risks
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September 28, 1989
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Diuretics, the most widely used class of drugs against high blood pressure, can cause biochemical changes that make people more susceptible to heart attacks, researchers have found.
The findings add significantly to the growing scientific evidence that the benefit of diuretics in lowering blood pressure may be offset, at least in part, by other adverse effects. The accumulating data have led some prominent researchers to urge that diuretics not be used as the initial drug treatment for hypertension.
Diuretics are one of four classes of drugs recommended by the National Heart, Lung, and Blood Institute as initial medications for lowering blood pressure. The three other classes are ACE inhibitors, beta blockers and calcium channel blockers. It is not normally a medical problem for patients to switch from one of these four kinds of drug to another, physicians say. Impact on Body Tissues
Diuretics, called ''water pills'' because they eliminate water from the body, reduce blood pressure by depleting the body of sodium. The researchers found that the drugs act directly on body tissues to cause a sort of chemically induced diabetes and also increase blood cholesterol levels.
An estimated 60 million Americans have blood pressure high enough to require treatment, and 15 million to 25 million of them take diuretics, The study, by Dr. Thomas Pollare, Dr. Hans Lithell, and Dr. Christian Berne of the University of Uppsala in Sweden, is being reported today in The New England Journal of Medicine. The researchers studied the diuretic hydrochlorothiazide, which is typical of this class of drugs. Other diuretics include thiazide and chlorothiazide, . Several experts said the findings mean that doctors should reconsider the methods they use to treat high blood pressure. But others expressed support for diuretics and their value in treating hypertension. ''This is a major study,'' said Dr. Randall Zusman, director of the division of hypertension and vascular medicine of the Massachusetts General Hospital in Boston. ''It should make a difference.'' Differing Reactions
Dr. Thomas D. Giles, director of the cardiovascular research laboratory at Tulane University in New Orleans, agreed. ''It's amazing how we've gone along using these agents for so many years without carefully scrutinizing their possible offsetting effects,'' he said.
But Dr. Edward J. Roccella, coordinator of the National High Blood Pressure Education Program of the National Heart, Lung, and Blood Institute, said diuretics remained ''an important class of drugs in the management of hypertension,'' adding, ''Their efficacy has been demonstrated and they are reasonably priced.''
Diuretics, the oldest and best studied of the drugs used to lower blood pressure, are also taken for other conditions, like congestive heart failure. Some people take over-the-counter diuretics to lose weight or prevent bloating. Their vulnerability to the drugs' side effects would depend on how long they took them and in what dose.
Large clinical trials have demonstrated that the drugs can reduce major complications of high blood pressure, including strokes, kidney failure and heart failure, which results when the heart fails to pump strongly enough. But the studies have not shown that diuretics can prevent heart attacks.
''Every study that has ever been done has shown no change or an increase in heart attacks,'' said Dr. John Laragh, who is director of hypertension and cardiovascular center and chief of cardiology at New York Hospital-Cornell Medical Center. ''Eighty percent of the increased mortality and morbidity with high blood pressure is assignable to a predisposition of heart attack.''
Dr. Roccella said the studies ''were not designed to show changes'' in heart attack rates and he suspects that patients who reduce their blood pressure with diuretics may have fewer heart attacks. But others are highly skeptical. Comparisons in the Study
The new study compared hydrochlorothiazide to captopril, a member of another class of drug, ACE inhibitors, which reduce blood pressure by relaxing blood vessels. Captopril is made by Squibb, which paid part of the study costs. Two other ACE inhibitors are on the market: enalapril, made by Merck Sharpe & Dohme, and lisinopril, marketed by Merck and ICI.
Merck also makes hydrochlorothiazide and has done similar similar studies comparing it to enalapril. In a statement yesterday, Robert Sincovich, a company spokesman, said: ''We continue to feel that both drugs are appropriate first-line therapies for many patients.''
In their study, the Swedish researchers gave 50 patients either hydrochlorothiazide or captopril, without revealing to the doctors or patients in the study which patients got which drug. After four months, they switched the drugs so the patients who had been taking hydrocholorothyizide got captopril and those taking captopril got hydrochlorothiazide.
The investigators found that when the patients took hydrochlorothiazide, their tissues were less responsive to the hormone insulin. Such insulin resistance increases the risk of heart disease. In addition, the patients' cholesterol levels were about 15 percent higher when they took the diuretic. Captopril had opposite biochemical effects, making tissues more sensitive to insulin and reducing cholesterol levels.
Dr. Lithell said his group also had studied the two other leading classes of blood pressure drugs - calcium channel blockers and beta blockers. Calcium channel blockers, which relax blood vessels, had no effect on insulin sensitivity and cholesperol levels. Beta blockers which rest the heart and slow the pulse, raised cholesterol levels, he found. Yet, Dr. Laragh said, beta blockers have also been shown to reduce the chances that a man who had one heart attack will have a second one. Yearly Costs of Drugs
But diuretics and beta blockers, which are available as generic drugs, cost far less than the newer drugs. A generic diuretic costs as little as $30 a year, and even if a patient also takes a potassium supplement to make up for the mineral loss that is commmon with the drug, the yearly cost of treatment is about $200 to $240 a year, said Dr. Marvin Moser of Yale univeristy School of Medicine.
A generic beta blocker costs about $175 a year, Dr. Moser said. The newer drugs, like captopril or its three close competitors or the calcium channel blockers cost $400 to $700 a year, he said.
Dr. Moser said he favored staying with diuretics as a first drug therapy for high blood pressure because they are inexpensive and have been studied for years, in contrast to the newer drugs whose possible long-term side effects have not been established. He said doctors have been pressed to switch to the newer drugs by advertising from drug companies who see a lucrative market.
But others like Dr. Laragh said they are convinced that most patients should not use diurectics as an initial drug to lower blood pressure. And patients who already have diabetes should be especially leery of the drugs, he said.
Dr. Laragh said the new study was another reason to re-evaluate the usual clinical practice of reaching for a diuretic when a new patient comes in with high blood pressure.
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