Influence of diabetes and type of hypertension on response to antihypertensive treatment. Results of combination anti-hypertensive therapy after failure of each of the components. Department of Veterans Affairs Cooperative Study Group on Anti-hypertensive Agents. Beta-blockers versus diuretics in hypertensive men: main results from the HAPPHY trial. Effect of withdrawal of antihypertensive drug on depressive mood. South African hypertension guideline 2011. Long-acting and short-acting diuretics in mild essential hypertension. [The effect of an antihypertensive drug during psychological stress. A double-blind study]. Additional Antihypertensive Effect of Drugs in Hypertensive Subjects Uncontrolled on Diltiazem Monotherapy: A Randomized Controlled Trial Using Office and Home Blood Pressure Monitoring Duration of antihypertensive effect of a single daily dose of hydrochlorothiazide Antihypertensive actions of diuretics. Comparative study of an aldosterone antagonist and a thiazide, alone and together. Interaction of enalapril with sodium restriction, diuretics, and slow-channel calcium-blocking drugs. Treatment of hypertension in the elderly: II. Cognitive and behavioral function. Results of a Department of Veterans Affairs Cooperative Study. Effects of thiazide diuretics on plasma lipids and lipoproteins in mildly hypertensive patients: a double-blind controlled trial. ACE inhibitors, beta-blockers, calcium blockers, and diuretics for the control of systolic hypertension. The use of clonidine monotherapy in adolescent hypertension. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. Diet or diuretic? Treatment of newly diagnosed mild to moderate hypertension in the elderly
The aim of our investigation was to determine whether the presence of additional risk factors or type of hypertension ( diastolic or isolated systolic ) influences blood pressure ( BP ) response to treatment . The International Nifedipine GITS Study : Intervention as a Goal in Hypertension Treatment ( INSIGHT ) study is a double-blinded outcome comparison of calcium channel blockade with diuretics in high-risk patients aged 55 to 80 years . Dynamic r and omization between nifedipine once daily and hydrochlorothiazide/amiloride was performed to ensure that approximately equal numbers of patients in the 2 groups had each of the major cardiovascular risk factors . Patients with isolated systolic hypertension were also separately r and omized . Atenolol or enalapril was the m and atory second-line drug . In 5669 patients who completed the 18-week titration , BP fell from 172+/-15/99+/-9 mm Hg ( mean+/-SD ) while receiving placebo to 139+/-12/82+/-7 mm Hg . Twenty-six percent of patients required 2 drugs , and 4 % required 3 drugs . Patients with diabetes were the most resistant to treatment , requiring second and third drugs 40 % and 100 % more frequently than patients without diabetes and achieving marginally the highest final BP , for any risk group , of 141+/-13/82+/-8 mm Hg . Age , smoking , gender , hypercholesterolemia , left ventricular hypertrophy , and existing atherosclerosis had little ( < 1 mm Hg ) or no influence on BP at the end of titration , but all except smoking slightly reduced the initial response of either systolic or diastolic BP . Patients with isolated systolic hypertension were slightly more responsive than average to treatment . Our findings suggest that in patients at high absolute risk of cardiovascular complications from hypertension , the risk factors themselves do not prevent the recommended BP targets from being achieved We r and omised ambulatory men with diastolic blood pressure ( BP ) 95 - 109 mmHg without anti-hypertensive medication to single drug treatment with either  hydrochlorothiazide 12.5 - 50 mg/day , atenolol 25 - 100 mg/day , captopril 25 - 100 mg/day , clonidine 0.2 - 0.6 mg/day , diltiazem-SR 120 - 360 mg/day , prazosin 4 - 20 mg/day or placebo in a double-blind prospect i ve trial . The assigned drug was titrated to a goal BP of < 90 mm Hg . Patients not achieving goal BP were rer and omised to an alternative single active drug . Non-responders to the second drug received the first drug in combination with the second . Of the 102 non-responders to both drugs who qualified for the combination , 59 ( 57.8 % ) responded . The combination pairs that included a diuretic achieved diastolic goal BP in 69 % and < 140 mm Hg systolic in 77 % compared with 51 % and 46 % , respectively , for those combinations without a diuretic ( P = 0.067 ; P = 0.002 ) . Six of the eight terminations due to adverse drug reactions were in combinations containing prazosin ; three of these six were hypotensive reactions . We conclude that two single drugs of insufficient efficacy to control BP individually have a high probability of achieving goal BP when combined , especially if the combination contains a diuretic Men aged 40 - 64 years with mild to moderate hypertension [ diastolic blood pressure ( DBP ) 100 - 130 mmHg ] were r and omized to treatment with a  diuretic ( n = 3272 ) or a  beta-blocker ( n = 3297 ) , with additional drugs if necessary , to determine whether a beta-blocker based treatment differs from thiazide diuretic based treatment with regard to the prevention of coronary heart disease ( CHD ) events and death .  Patients with previous CHD , stroke or other serious diseases , or with contraindications to diuretics or beta-blockers were excluded . If normotension ( DBP less than 95 mmHg ) was not achieved by monotherapy , other antihypertensive drugs were added , but the two basic drugs were not crossed over . Patients were assessed at 6-monthly intervals . The mean follow-up for end-points was 45.1 months . Blood pressure ( BP ) side effects and end-points were recorded in a st and ardized manner . Entry characteristics and the BP reduction achieved were very similar in both treatment groups . All analyses were made on an intention-to-treat basis . The incidence of CHD did not differ between the two treatment groups . The incidence of fatal stroke tended to be lower in the beta-blocker treated group than in the diuretic treated group . Total mortality and the total number of end-points were similar in both groups . The percentage of patients withdrawn due to side effects was similar , whereas the number of reported symptoms , according to a question naire , was higher for patients on beta-blockers . The incidence of diabetes did not differ between the two groups . Subgroup analyses did not detect a difference in the effect of beta-blockers compared with diuretics in smokers as opposed to non-smokers , and beta-blockers also had the same effects as diuretics in the quartile with the highest predicted risk for CHD . Beta-blockers and thiazide diuretics were approximately equally well tolerated . The two drugs had a similar BP reducing effect although additional drugs had to be given more often in the diuretic group . Antihypertensive treatment based on a beta-blocker or on a thiazide diuretic could not be shown to affect the prevention of hypertensive complications , including CHD , to a different extent To evaluate the effects on depressive mood of withdrawal of antihypertensive medication , we conducted a r and omized , multi-center study with clinical centers at the Albert Einstein College of Medicine , Bronx , NY , University of Alabama School of Medicine , Birmingham , and the University of Mississippi School of Medicine in Jackson . Patients were formerly active participants in the Hypertension Detection and Follow-Up Program ( HDFP ) whose blood pressure was controlled with drugs for a period of 5 years . Of 496 patients , 431 had both baseline and " 1-year " mood scores . Patients , stratified by obesity , were r and omized to one of three groups : continue the HDFP medication ; discontinue medication with no dietary intervention , or with sodium restriction and potassium increase ; or , for those overweight , to a weight reduction intervention .  Depression was assessed using the CES-D scale ( Center for Epidemiological Studies --Depressed Mood ) , administered at baseline and again approximately 1 year after r and omization . Of the seven treatment groups , only those who continued their HDFP medication showed significant improvement in mood from baseline . The overweight continue-medication group showed significantly greater improvement compared to the no-drugs , no-diet intervention groups , and to the overweight sodium-restriction group . Patients who had their blood pressure successfully controlled with weight reduction had a significant improvement in mood from 11.0 scale points to 8.0 , P = .006 . Comparisons between those withdrawn from diuretic alone and those withdrawn from both diuretic plus reserpine were inconclusive . Dietary Intervention Study of Hypertension ( DISH ) shows no evidence that continued use of chlorthalidone has a negative impact on quality of life , while our results concerning reserpine were inconclusive . ( ABSTRACT TRUNCATED AT 250 WORDS OUTCOMES Extensive data from r and omised controlled trials have shown the benefit of treating hypertension . The target blood pressure ( BP ) for antihypertensive management is systolic < 140 mmHg and diastolic < 90 mmHg with minimal or no drug side-effects ; however , stricter BP control is required for patients with end-organ damage , co-existing risk factors and co-morbidity , e.g. diabetes mellitus . The reduction of BP in the elderly and in those with severe hypertension should be achieved gradually over 1 month . Co-existent risk factors should also be controlled . BENEFITS Benefits of management include reduced risks of stroke , cardiac failure , chronic kidney disease and coronary heart disease . RECOMMENDATIONS The correct BP measurement procedure is described , and evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy are stipulated . The total cardiovascular disease risk profile should be determined for all patients to inform management strategies . Lifestyle modification and patient education are cornerstones in the management of every patient . Major indications , pre caution s and contra-indications to each recommended antihypertensive drug are listed . Combination therapy should be considered ab initio if the BP is ≥ 20/10 mmHg . First-line drug therapy for uncomplicated hypertension includes low-dose thiazide-like diuretics , calcium channel blockers ( CCBs ) or angiotensin-converting enzyme inhibitors ( ACE-Is ) ( or ARBs - angiotensin II receptor blockers ) . If the target BP is not obtained , a second antihypertensive should be added from the aforementioned list . If the target BP is still not met , the third remaining antihypertensive agent should be used . In black patients  either thiazide-like diuretics or CCBs can be used initially , because response rates are better than with ACE-Is or β-blockers . In treating resistant hypertension , a central ly acting drug , vasodilator , α-blocker , spironolactone or β-locker should be added . This guideline includes management of specific situations , i.e. hypertensive emergency and urgency , severe hypertension with target organ damage , hypertension in diabetes mellitus , resistant hypertension , fixed drug combinations , new trials in hypertension , and interactions of antihypertensive agents with other drugs . VALIDITY The guideline was developed by the Southern African Hypertension Society A r and omised , placebo-controlled , double-blind crossover study was conducted in 14 patients with mild essential hypertension comparing different regimens of administration of the " short-acting " diuretic , chlorothiazide and the " long-acting " diuretic , chlorthalidone . There were 6 r and omised treatment phases each of 5 weeks duration . For blood pressure recorded both at the Clinic and at home the most prominent effects were seen with st and ing blood pressure , for which significant reductions of mean blood pressure compared to the placebo phase were observed with chlorthalidone 25 mg once daily ( -5 + /- 1 ( SE ) mm Hg - p less than 0.05 ) , chlorthalidone 50 mg once daily ( -7 + /- 1 mm Hg - p less than 0.01 ) and chlorothiazide 500 mg twice daily ( -4 + /- 1 mm Hg - p less than 0.05 ) . Blood pressure reductions with chlorothiazide 500 mg once daily and 1000 mg once daily were not significant . About half of the patients completing the trial could be described as " non-responders " . The observed biochemical changes ( reduced plasma potassium and chloride concentrations and increased plasma bicarbonate and urate concentrations ) were most marked in the phases with the most prominent blood pressure effects . The result support the suggestion that a sustained diuretic effect is desirable when diuretics are used in the treatment of hypertension . This can be obtained by selection of the appropriate dosage regimen for a particular diuretic , such as once daily administration for " long-acting " and twice daily for " short-acting " thiazide-type diuretics A sample of 20 patients suffering hypertension ( with a moderate rise in blood pressure ) was r and omly divided into two treatment groups of equal size . The patients of one group received antihypertension treatment with the combination drug Briserin ¿ ( containing 0.1 mg reserpine , 5 mg clopamide , 0.5 mg dihydroergocristin/per tablet ) ; the other patients who served as  control group  , received a matched placebo . After a fortnight 's treatment , the responsiveness of both groups to five different psychologically stressing situations ( those with cognitive and /or emotional overload ) was tested . Analysis of covariance revealed clinical ly significant differences in the mean systolic and diastolic pressure scores of the two groups . The scores of the treatment group were lower not only under stress but also at rest . There was in interaction between rise of blood pressure under stress and kind of stress in the two groups , i.e. , in situations with heavy emotional and /or cognitive load the differences in the pressure scores of the two groups were less substantial than in situations with a low or medium load . The treatment had no systematic effect on heart rate in this sample . In the treatment group reaction time , perceptual speed , and short-term memory were impaired as compared with the control group ; but these differences did not reach a level of significance The purpose of this study was to compare several diltiazem-based antihypertensive drug combinations and assess the usefulness of home blood pressure monitoring in the evaluation of the efficacy of combination pharmacotherapy . Sixteen general practitioners recruited hypertensive subjects uncontrolled on diltiazem monotherapy , who were r and omized to receive eight weeks of add-on therapy with a diuretic ( chlorthalidone ) , a dihydropyridine calcium antagonist ( felodipine ) , an ACE inhibitor ( lisinopril ) , or an angiotensin blocker ( valsartan ) .  Sitting office and home blood pressure was measured using electronic devices A&D 767 . A total of 211 patients were r and omized , and 185 completed the study . Of 52 subjects r and omized to felodipine  , 15 were withdrawn due to ankle edema . The additional antihypertensive effect of the second drug was smaller in 18 subjects with a white coat effect ( p < 0.01 ) . All combinations produced a significant decline in office ( 21.2 ± 14.8 / 7.7 ± 9.7 mmHg ) and home ( 17.1 ± 11.9 / 6.0 ± 7.0 ) blood pressure ( systolic / diastolic , p < 0.001 ) . There were no differences in the efficacy of the four combinations assessed using office or home blood pressure monitoring . These data suggest that diuretics , dihydropyridines , ACE inhibitors , and angiotensin receptor blockers provide significant additional antihypertensive effects in hypertensive patients uncontrolled on diltiazem monotherapy . The diltiazem-dihydropyridine combination is often intolerable because of ankle edema . Home blood pressure monitoring is useful in the assessment of the efficacy of combination pharmacotherapy and also allows for the detection of subjects who do not require treatment intensification To assess the duration of antihypertensive effect of a single daily dose of the short‐acting diuretic hydrochlorothiazide , a double‐blind crossover study was performed in 11 patients previously well controlled with diuretics . Each patient received hydrochlorothiazide 100 mg in the morning for 12 wk and blood pressures were recorded 4 times daily ( 8 A.M. , 12 noon , 4 A.M. , and 8 P.M. ) on 3 separate visits . The crossover design also included a 12‐wk placebo period either preceding or following active therapy . Blood pressure control was excellent and sustained throughout the day in all patients studied , indicating that a single daily dose of hydrochlorothiazide is a suitable regimen for hypertension therapy . The use of a placebo period before initiating the trial and during the active part of the trial confirmed the observation that patients who have been adequately treated for long periods will maintain lowered blood pressure for a variable period after stopping therapy Hydrochlorothiazide in a daily dose of 150 mg and spironolactone in a daily dose of 400 mg ( 100 mg of the currently available preparation ) were found to have equivalent antihypertensive effects — reducing basal blood pressure , decreasing the pressor response to levarterenol bitartrate ( norepinephrine ) and angiotensin amide , and increasing the depressor response to a ganglion-blocking agent , trimethaphan camsylate — in a double-blind study of 11 hypertensive patients . The two diuretics , when given together , appear to act independently and additively in their antihypertensive effects . Serum potassium level , lowered by hydrochlorothiazide , was in the normal range during administration of spironolactone alone or in combination with hydrochlorothiazide . Spironolactone can thus be a useful substitute for a benzothiadiazine derivative in the treatment of hypertension . The administration of a combination of these diuretics , a thiazide and an aldosterone antagonist , can render hypertension more readily manageable While monotherapy sometimes controls blood pressure ( BP ) , it is often essential to add a second drug for adequate control . This study examined in a factorial fashion the interaction of enalapril with some commonly used antihypertensive therapies .  There were between 10 and 16 patients in each study , and the patients had responded in part to the two drugs used .  Enalapril and sodium restriction lowered BP 12 + /- 3/11 + /- 2 and 4 + /- 2/3 + /- 1 mm Hg , respectively . The effects of the two therapies were additive , and there was no interaction . Enalapril and hydrochlorothiazide  lowered BP 11 + /- 3/8 + /- 3 and 8 + /- 2/6 + /- 2 mm Hg , respectively . The effect of the two drugs together indicated a positive interaction of 4 + /- 2/3 + /- 1 mm Hg ( p less than 0.05 ) . Enalapril and nifedipine both lowered BP ( 10 + /- 2/8 + /- 1 and 11 + /- 3/8 + /- 1 mm Hg ) . The two drugs combined had a strongly positive interaction of 10 + /- 3/7 + /- 2 mm Hg ( p less than 0.001 ) . Enalapril can be used with the other therapeutic methods tested . If a converting enzyme inhibitor does not reduce BP adequately , it appears appropriate to add a thiazide diuretic or a slow-channel calcium-blocking drug . The mechanism of the positive interaction with diuretics probably reflects an effect on the renin-angiotensin system , but the explanation for the synergism with slow-channel calcium-blocking drugs is unclear This study was design ed to determine whether blood pressure reduction , per se , causes adverse effects on cognitive and behavioral function in elderly hypertensive patients . Men with mild-to-moderate diastolic hypertension who had passed their 60th birthday were entered into the trial . After a placebo washout period , they were assigned in a r and omized , double-blind manner to one of two groups receiving hydrochlorothiazide ( either 25 mg once or twice daily or 50 mg once or twice daily ) . Responders entered a 1-year maintenance period . Nonresponders were r and omly assigned to double-blind treatment with hydralazine , methyldopa , metoprolol , or reserpine added to the diuretic therapy . During the placebo and treatment periods , patients underwent a battery of psychometric tests design ed to assess cognitive function , motor skills , memory , and affect . A separate question naire assessed the patient 's ability to perform activities of daily living . A subset of patients blindly being treated with placebo received the same battery of tests as a control for practice effect . The results showed that there was similar improvement on the psychometric tests between those patients whose blood pressure was successfully reduced and the placebo-treated control group . Therefore , the practice effect did not obscure a true deterioration in function . There were no substantive differences between the lower and higher doses of diuretic or among the four drugs added to the diuretic , although there were qualitative differences in side effects . We conclude that blood pressure reduction , per se , does not adversely affect cognitive and behavioral function in elderly hypertensive patients and that antihypertensive treatment is safe and effective in these patients A blood lipid-lipoprotein elevating effect of the diuretics hydrochlorothiazide and chlorthalidone in mildly hypertensive men has been established by a cross-over , r and omized controlled trial , confirming previous clinical observations . Compared to baseline , plasma total cholesterol increased 6 % and 8 % and triglycerides 17 % and 15 % under treatment with hydrochlorothiazide and chlorthalidone , respectively . A cholesterol-lowering diet largely prevents this increase . Because these effects may be long-lasting and may cancel part of the potential benefit of blood pressure control in mildly hypertensive patients , with thiazide diuretics attention should be given to prescription of a cholesterol-lowering diet and to periodic monitoring of blood lipid levels . Different antihypertensive agents might be considered in patients with elevated blood lipid levels . Other antihypertensive agents currently in use need to be studied for potential effects on lipid metabolism The objective of this study was to determine which of the common groups of antihypertensive drugs is most effective at lowering systolic blood pressure ( SBP ) in elderly patients with previously untreated hypertension and the percentage of patients controlled with single or sequential monotherapy . Subjects were recruited from patients attending other outpatient clinics and entered into the study if their SBP was more than 150 mm Hg after three visits . Patients were given a low and high dose of each of the main classes of drugs or placebo for 1 month each . The study was a balanced , r and omized crossover design with five periods : placebo ; angiotensin converting enzyme inhibitors ; beta-blocking drugs ; calcium-blocking drugs ; and thiazide diuretics .  Blood pressure ( BP ) was measured 24 to 26 h after the previous dose . A question naire for side effects was administered at each visit . Seventy-four patients entered the study . beta-Blockers could not be used in 15 patients because of asthma or bronchospasm and these had two placebo periods . There were 9 of 66 patients on P , 9 of 46 on beta-blockers , 4 of 65 on calcium-blocking drugs , 4 of 65 on diuretic , and 1 of 62 patients on ACE inhibitors who did not progress to the higher dose because of side effects . Decreases in SBP compared to r and omized placebo were calcium-blocking drugs 15 mm Hg = diuretic 13 mm Hg > ACE inhibitors 8 mm Hg = beta-blockers 5 mm Hg . Blood pressure decrease correlated with placebo BP ( P < .0005 , r = 0.53 to 0.70 ) . When corrected for placebo , target SBP ( < 140 mm Hg ) was reached in between 6 % to 15 % of patients on monotherapy . Sequential monotherapy achieved target in 29 % . Angiotensin converting enzyme inhibitors , calcium-blocking drugs , and diuretics had no more side effects than placebo . Patients on beta-blockers had more side effects and the well-being score was reduced . Diuretics and calcium-blocking drugs are more effective in elderly patients at lowering SBP pressure . beta-Blockers were relatively ineffective , were frequently contraindicated , and had more side effects . Monotherapy achieved control in only a small number of patients . In elderly people with essential hypertension , therapy should be instituted with diuretics or calcium-blocking drugs , but combination therapy will usually be required to achieve goal The effect of a central ly acting agent ( clonidine ) vs a diuretic as a single agent was studied in a group of hypertensive adolescents . Following placebo therapy , adolescents with blood pressure greater than 95th percentile were r and omized to clonidine 0.1 mg or hydrochlorothiazide 25 mg , each given twice daily . Following 12 weeks ' active treatment , those who had not achieved blood pressure goals proceeded to clonidine 0.2 mg or hydrochlorothiazide 50 mg twice daily . Blood pressure and clinical assessment was performed at two-week intervals . Cardiovascular response to mental stress and pre-post stress catecholamines were obtained prior to active therapy and during therapy . Clonidine therapy significantly lowered systolic and diastolic pressure and heart rate ( p less than .01 ) . Hydrochlorothiazide significantly lowered systolic pressure only . Mental stress testing result ed in a lower diastolic pressure and heart rate response ( p less than .01 ) , with lower norepinephrine in the clonidine-treated group . The diuretic group had higher plasma norepinephrine and no significant reduction in stress response . Hypertensive juveniles may be more sensitive to central control of blood pressure and more resistant to diuretics OBJECTIVE To assess the effect of low-dose , diuretic-based antihypertensive treatment on major cardiovascular disease ( CVD ) event rates in older , non-insulin-treated diabetic patients with isolated systolic hypertension ( ISH ) , compared with nondiabetic patients . DESIGN Double-blind , r and omized , placebo-controlled trial : the Systolic Hypertension in the Elderly Program ( SHEP ) . SETTING Multiple clinical and support centers in the United States . PARTICIPANTS A total of 4736 men and women aged 60 years and older at baseline with ISH ( systolic blood pressure [ BP ] , > or = 160 mm Hg ; diastolic BP , < 90 mm Hg ) at baseline , 583 non-insulin-dependent diabetic patients and 4149 nondiabetic patients ( 4 additional patients not so classifiable were r and omized but not included in these analyses ) . Diabetes mellitus defined as physician diagnosis , taking oral hypoglycemic drugs , fasting glucose level of 7.8 mmol/L or more ( > or = 140 mg/dL ) , or any combination of these characteristics . INTERVENTION The active treatment group received a low dose of chlorthalidone ( 12.5 - 25.0 mg/d ) with a step-up to atenolol ( 25.0 - 50.0 mg/d ) or reserpine ( 0.05 - 0.10 mg/d ) if needed . The placebo group received placebo and any active antihypertensive drugs prescribed by patient 's private physician for persistently high BP . MAIN OUTCOME MEASURES The 5-year rates of major CVD events , nonfatal plus fatal stroke , nonfatal myocardial infa rct ion ( MI ) and fatal coronary heart disease ( CHD ) , major CHD events , and all-cause mortality . RESULTS The SHEP antihypertensive drug regimen lowered BP of both diabetic and nondiabetic patients , with few adverse effects . For both diabetic and nondiabetic patients , all outcome rates were lower for participants r and omized to the active treatment group than for those r and omized to the placebo group . Thus , 5-year major CVD rate was lower by 34 % for active treatment compared with placebo , both for diabetic patients ( 95 % confidence interval [ CI ] , 6%-54 % ) and nondiabetic patients ( 95 % CI , 21%-45 % ) . Absolute risk reduction with active treatment compared with placebo was twice as great for diabetic vs nondiabetic patients ( 101/1000 vs 51/1000 r and omized participants at the 5-year follow-up ) , reflecting the higher risk of diabetic patients . CONCLUSION Low-dose diuretic-based ( chlorthalidone ) treatment is effective in preventing major CVD events , cerebral and cardiac , in both non-insulin-treated diabetic and nondiabetic older patients with ISH The aim of this study was to assess the effectivity of dietary measures in the treatment of hypertension . Therefore , a single-blind r and omised clinical trial was carried out in elderly persons with recently diagnosed hypertension . Patients were recruited from a general practice ( 6555 persons ) during visits or after written invitation or invitation by phone . New hypertensive patients ( with measurements taken on three different occasions > 159 mm Hg systolic and /or > 94 mm Hg diastolic ) , aged 60–80 years , without target-organ damage , dementia , diabetes mellitus or malignant disease entered a 3-month intervention programme of either intensive dietary counselling , receiving a sodium-reduced ( < 100 mmol/24h ) , potassium-enriched ( > 75 mmol/24h ) , and weight-reducing diet ( BMI < 25 ) , or only 25 mg chlorthalidone a day .  forty-two newly diagnosed hypertensive subjects met the inclusion criteria . two dropped out from the chlorthalidone group , one with side effects and another after a myocardial infa rct ion . although blood pressure ( bp ) in the diet group decreased less than in the drug group , of the patients in the diet group 45 % fell back to a normal systolic and 50 % to a normal diastolic bp ( drug treatment group , systolic 75 % and diastolic 85 % ) . in contrast with the diet group , lipid spectrum and blood glucose concentration in the diuretic group , however , deteriorated slightly . the dietary intervention was effective in elderly patients with a systolic or diastolic bp in the range of 160–180 and 95–100 mm hg , respectively . reduction in weight should be the primary aim . it is argued that sodium reduction can be achieved better by collective measures . in patients with a bp of more than 180 mm hg systolic or 100 mm hg diastolic , dietary advice and drug treatment should be combined
The effect was similar to that obtained when thiazides are used as a single agent .
Thiazides when given as a second-line drug have a dose related effect to lower blood pressure that is similar to when they are added as a first-line drug .
This means that the BP lowering effect of thiazides is additive .
Loop diuretics appear to have a similar blood pressure lowering effect as thiazides at 1 times the recommended starting dose .
Because of the short duration of the trials and lack of reporting of adverse events , this review does not provide a good estimate of the incidence of adverse effects of diuretics given as a second-line drug
BACKGROUND Diuretics are widely prescribed for hypertension not only as a first-line drug but also as a second-line drug .
Therefore , it is essential to determine the effects of diuretics on blood pressure ( BP ) , heart rate and withdrawals due to adverse effects ( WDAEs ) when given as a second-line drug .