?-Blocker monotherapy and anticipated occurrences of heart failure in hypertensive veterans

To the Editor: The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) reported twice the risk of heart failure in hypertensive patients receiving doxazosin versus chlorthalidone, resulting in one additional occurrence of heart failure for every 27 patients treated during 4 years.1,2 Further analysis revealed that the higher risk of heart failure is attenuated, but not eliminated, with the addition of other antihypertensive drugs.3 However, controversy remains regarding potentially confounding variables, such as the withdrawal of baseline antihypertensives (ie, diuretics) before randomization. This may have contributed to the reported association between the use of doxazosin and heart failure.4 Conversely, it is of interest that in chronic heart failure the Veterans affairs vasodilator Heart Failure Trial (V-HeFT) reported that prazosin was no different from placebo with regard to the primary end points of the trial, but a review of reasons for permanent discontinuation of study drugs reveals that 8.2% of patients randomized to prazosin discontinued therapy secondary to increased congestive heart failure versus 5.5% of the patients randomized to placebo (P value not provided).5 Although modest declines in the prescribing of α-blockers between 1999 and 2002 have been reported, the prevalence of α-blocker monotherapy for hypertension in various populations and subsequent estimation of additional heart failure occurrences that may be expected have not been previously described.6