THE PLACE OF DIURETICS IN ANTIHYPERTENSIV E THERAPY

The ultimate aim in treating hypertension is to reduce cardiovascular mortality and morbidity, especially from coronary heart disease and st rokes. In several long-term trials this goal has been achieved with an tihypertensive therapy in the form of diuretics. Subsequently, diureti cs and betablockers, compared as single agents or with the addition of other agents, did not appear to affect overall cardiovascular morbidi ty and mortality differentially. Therefore, recommended first-line the rapy for hypertension was initially diuretics, followed later by beta- blockers as alternatives. Recently, calcium antagonists and ACE inhibi tors have been accepted as equally valuable in the treatment of hypert ension because they similarly lower blood pressure, lack any adverse m etabolic effects and may be more beneficial than diuretics or beta-blo ckers on the long-term prognosis of hypertensive patients. Such recomm endations are, however, highly speculative and are not supported by tr ials using cardiovascular mortality and morbidity as endpoints. In ord er to solve the conflict between proven facts and sound theory, long-t erm trials comparing older (mainly diuretics) and newer (calcium antag onists, ACE inhibitors, alpha-adrenoceptor blockers) antihypertensive agents are needed. Until such trials are completed, the debate surroun ding first-line drugs for antihypertensive treatment will nor be resol ved.