What is The Best Treatment for Hypertension in Obesity?

Regular readers will note my past interest in hypertension, especially with regard to managing this condition in people with excess weight.

A paper by Michael Weber and Colleagues, now presents an analysis of the relationship between body size and hypertension treatments on cardiovascular event rates, in a paper published in The Lancet.

The paper consists of a prespecified analysis of the ACCOMPLISH (Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension) trial, that compared the effect of single-pill combinations of either benazepril and hydrochlorothiazide or benazepril and amlodipine on hard cardiovascular outcomes.

Based on BMI, the full ACCOMPLISH cohort was stratified into obese (n=5709), overweight (n=4157), or normal weight (n=1616) categories.

In patients allocated benazepril and hydrochlorothiazide, the primary endpoint (per 1000 patient-years) was 30·7 in normal weight, 21·9 in overweight, and 18·2 in obese patients.

In contrast, there were no differences in outcomes between the BMI groups in those allocated benazepril and amlodipine(18·2, 16·9, and 16·5, respectively).

From these findings the authors conclude that.

“..thiazide-based treatment may give less cardiovascular protection in normal weight than obese patients, but amlodipine-based therapy is equally effective across BMI subgroups and thus offers superior cardiovascular protection in non-obese hypertension.”

Given the known differences in physiology, where obesity related hypertension is largely mediated by volume expansion and sodium retention, these findings may not be all that surprising.

Clearly, including a diuretic in the treatment regimen for obesity related hypertension makes a lot of sense – now we have the outcome data suggesting that such a regimen also reduces hard outcomes.

Calgary, Alberta

Hat tip to Scott Kahan for alerting me to this study.