Effects of ACE Inhibition and Diuretic Therapy
Of all the modifiable risk factors for cardiovascular morbidity and mortality, left ventricular hypertrophy (LVH) is the most potent predictor. Though meta-analyses have suggested that ACE inhibitors fare most favorably for regression of LVH than the other classes of antihypertensives, few head-to-head comparisons with other agents exist. Also, limited literature suggests that arterial stiffness, which may reflect a cardiac workload in addition to blood pressure, is more beneficially reduced by ACE inhibitors than other agents.
This six-month randomized, double-blind trial followed 50 hypertensive patients on either an ACE inhibitor (ramipril up to 20 mg/d) or diuretic (HCTZ up to 50 mg/d). Measurements included serial echocardiography and carotid ultrasonography.
The most dramatic results demonstrated were a nonsignificant decrease (1.3%) in LVH with diuretics vs. a substantial decrease (7.3%) with ACE inhibitors. Though neither drug treatment effected a reduction in vessel wall thickness, diuretic-treated patients demonstrated vascular remodeling with significantly increased relative wall thickness. The authors comment that recent trials such as the Treatment of Mild Hypertension Study (TOMHS), which reflected superiority of diuretics over other classes of agents for the end point of LVH, are difficult to interpret since placebo recipients also achieved normotension and near normal ventricular mass.
The authors conclude that the superior LVH regression demonstrated with ACE inhibitors is in accord with much previous data and pathophysiologic correlates which delineate sustained angiotensin II as a stimulus to cardiac hypertrophy.
Roman MJ, et al. Am J Hypertens 1998;11:387-396.
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