The choice of antihypertensive therapy in patients with the metabolic syndrome--time to change recommendations?

Patients with hypertension and the metabolic syndrome have high risk of suffering from future cardiovascular and kidney disease. There are no large-scale, randomized trials to establish the antihypertensive drug of choice for this important group of patients, but several authors consider angiotensinconvertingenzymeinhibitors(ACEI)aspreferable, calcium channel blockers as intermediate, and betablockers as well as thiazide diuretics as less well suited (see for example the latest guidelines of the European Society of Hypertension [1]). This notion is primarily based on the metabolic side effects of thiazides and beta-blockers that may increase blood lipids and glucose, relative to ACEI and CCB [2]. Beta-blockers also promote weight gain, and both thiazides and beta-blockers are associated with an increased incidence of diabetes, compared to CCB and ACEI [3]. Wright et al. [4] have recently published a subgroup analysis of the ALLHAT study that appears to challenge the notion that thiazides and/or beta-blockers are second-line antihypertensive therapy in people with the metabolicsyndrome.Theseauthorsstatethattheir‘findings fail to support the preference for calcium channel blockers, alpha-blockers, or angiotensin-converting enzyme inhibitors compared with thiazide-type diuretics in patients with the metabolic syndrome, despite their more favorable metabolic profiles’ [4]. We will discuss this report in the context of the ongoing controversy over the interpretation of the results of ALLHAT [5,6,7]. The ALLHAT study [8] needs little introduction today: it was the largest trial ever performed in the field of hyper