Blood pressure treatment

William Cushman described the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), which had a total of 33,357 hypertensive participants, 36% of whom had diabetes, making it the largest study of blood pressure treatment in diabetes (1). Interestingly, 60% of the population studied satisfied criteria for the metabolic syndrome. In both the diabetic and nondiabetic subgroups, there was no difference in coronary heart disease (CHD) events or mortality between patients randomized to chlorthalidone, amlodipine, and lisinopril. Congestive heart failure (CHF) was less common with chlorthalidone than with the other agents. For those with fasting glucose <126 mg/dl at baseline, the mean glucose was 93 mg/dl at baseline, with levels increasing to 104 mg/dl with chlorthalidone, 103 mg/dl with amlodipine, and 101 mg/dl with lisinopril at 4 years. Similarly, diabetes incidence was highest with chlorthalidone at 11.6 vs. 9.8% with amlodipine and 8.1% with lisinopril. Including those persons who developed diabetes, and those with fasting glucose ≥126 mg/dl who had unrecognized diabetes, 39, 40, and 39% of persons in the three groups actually had diabetes. In each group, 4% had impaired fasting glucose (IFG) at levels of 110–125 mg/dl. The diabetic participants had 36% CVD prevalence, as opposed to 62% of the IFG and nondiabetic groups, based on the differing entry criteria for those with and without diabetes. Initial fasting glucose levels were 169, 116, and 91 mg/dl in the respective groups. Lisinopril did not lower systolic blood pressure as effectively as the two other agents, although it affected diastolic blood pressure similarly. Among persons with diabetes, at 2 years fasting blood glucose decreased 3 and 2 mg/dl with amlodipine …