Why the study?
The long-term comparative effectiveness of antihypertensive monotherapies in primary prevention of cardiovascular events needed to be determined.
Do different antihypertensive monotherapies (thiazides, CCBs, ACEIs, ARBs) reduce the risk of first major cardiovascular events compared to beta-blockers in patients without prior cardiovascular disease?
Cohort (n=33,427)
Do different antihypertensive monotherapies (thiazides, CCBs, ACEIs, ARBs) reduce the risk of first major cardiovascular events compared to beta-blockers in patients without prior cardiovascular disease?
Effect estimate: HR 0.88 (95% CI 0.81 to 0.95)
Absolute Event Rate: 22% vs 18.2%
In primary prevention, starting antihypertensive monotherapy with thiazides is associated with a lower risk of major cardiovascular events compared to beta-blockers, particularly in patients on diabetes drugs, whereas calcium channel blockers are associated with a higher risk.
Thiazides may be preferable to beta-blockers as initial monotherapy in primary prevention; leaves open randomized confirmation of cardiovascular outcomes.
OBJECTIVE: To determine the long-term effectiveness of antihypertensive monotherapies in primary prevention of cardiovascular events. DESIGN: Retrospective inception cohort study covering a 25-year study period. SETTING: University Groningen IADB.nl pharmacy prescription database with data from 1996 to 2020. PARTICIPANTS: Patients aged 18 years or older, free of any cardiovascular disease (CVD) drug therapies prior to initiation of a preventive antihypertensive monotherapy (ACE inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-blockers (BBs), calcium channel blockers (CCBs) and thiazides). OUTCOME MEASURES: Primary outcome was the time to first prescription of acute cardiac drug therapy (CDT) measured by valid drug proxies to identify a first major CVD event in patients without a history of CVD. RESULTS: Among 33 427 initiators, 5205 (15.6%) patients experienced an acute CDT. The average follow-up time was 7.9±5.5 years. The 25-year incidence rate per 1000 person-years were 25.3, 22.4, 18.2, 24.4 and 22.0 for ACEI, ARB, BB, CCB and thiazide starters, respectively. Inverse probability of treatment-weighted Cox regression showed that thiazide starters had lower hazards than the reference BB starters (HR: 0.88, 95% CI: 0.81 to 0.95). Among patients on diabetes drugs, risks were lower (HR: 0.49, 95% CI: 0.28 to 0.85). CCB starters had higher hazards than reference BB (HR: 1.21, 95% CI: 1.07 to 1.36). The overall estimated number needed to treat for thiazides compared with BBs to prevent one acute CDT in 25 years was 26, and four among patients on diabetes drugs. CONCLUSIONS: After adjustments for confounders, patients starting on monotherapy with thiazides had a lower incidence of CDT compared with those starting on BBs, notably among patients on diabetes drugs. Conversely, patients who began CCB monotherapy had a higher incidence of CDT compared with those starting on BBs. Other monotherapies had comparable incidence of cardiovascular disease compared with BBs.
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Li et al. (2023) conducted a cohort in Primary prevention of cardiovascular events (n=33,427). Antihypertensive monotherapies (thiazides, CCBs, ACEIs, ARBs) vs. Beta-blockers was evaluated on Time to first prescription of acute cardiac drug therapy (CDT) (HR 0.88, 95% CI 0.81 to 0.95).
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