Therapeutic implications of recent megatrials: in favor of old drugs

Abstract Data from controlled clinical studies comparing active drugs versus placebo or comparing different classes of drugs and their meta-analysis seem to indicate that although more subtle differences in the effects of various antihypertensive drugs cannot be ruled out, the protective effects against cardiovascular morbidity and mortality of all classes of drugs, including conventional therapy based on diuretics and beta-blockers and their combination, are largely explained by the extent of blood pressure (BP) reduction. Therefore BP control is still the main target of antihypertensive therapy. The benefits of diuretics have been well documented, particularly when these drugs are used at appropriate and/or optimal doses to achieve the optimal antihypertensive effect with the least occurrence of side effects, including negative metabolic effects. Therefore they must still be included among first line antihypertensive drugs. By contrast, beta-blockers seem recently to have lost their previously favored status as initial therapy for hypertension owing to their lower preventive effects against cardiovascular events as compared with diuretics in elderly hypertensive patients and against stroke as compared with other treatments, and to their negative metabolic effects. However, although evidence-based data must be taken into account, the choice of antihypertensive therapy aimed at BP control in individual patients must be made according to clinical characteristics. We believe that a wide range of choices among various antihypertensive drugs, above all diuretics and also betablockers, offers an appropriate possibility of selecting the right drug and the right combinations according to the clinical profile of the individual patient.