Allhat

Abstract

ALLHAT) studied high-risk hypertensive patients aged 55 years or older. ALLHAT was a large, simple trial, designed in a fashion to presumably mimic clinical practice as it occurs in high-risk patients. Its goals were to determine whether the incidence of the primary outcome-a composite of fatal coronary heart disease (CHD) and nonfatal myocardial infarction (MI)-differed between treatment with a thiazide-type diuretic (chlorthalidone [12.5 to 25.0 mg/d] and treatment with each of 3 other types of antihypertensive drugs-a calcium-channel blocker (CCB; amlodipine [2.5 to 10.0 mg/ d]), an angiotensin-converting enzyme (ACE) inhibitor (lisinopril), and a peripheral ␣-adrenergic blocker (doxazosin [1 to 8-mg/d]). The ALLHAT study did not include a washout or a medication-tapering period unless the latter was warranted for safety reasons. 1,2 Secondary outcomes included all causes of mortality, stroke, and all major cardiovascular disease events. If patients did not meet the blood pressure (BP) goal with the maximum tolerated dose of the initial medication, an open-label step 2 agent (atenolol, 25 to 100 mg/d; reserpine, 0.05 to 0.2 mg/d; or clonidine, 0.1 to 0.3 mg twice daily) or an open-label step 3 agent (hydralazine, 25 to 100 mg twice daily) could be added. In addition, a number of ALLHAT participants (n ϭ 10,337) participated in a randomized, open-label trial designed to determine whether lowering low-density lipoprotein cholesterol with the 3-hydroxy-3-methyl-glutaryl coenzyme A-reductase inhibitor pravastatin reduced all cause mortality compared with a control group receiving usual care. 3 ALLHAT set out to answer a number of very specific questions but in the process, not surprisingly, several other questions emerged. This editorial piece both frames the question and offers selected commentary. WHAT WERE THE RENAL FINDINGS FROM ALLHAT?ALLHAT in its original design considered renal function among the final trial outcomes. In this regard, 2 aspects of renal function were available for evaluation: first, the change in the slope of the reciprocal of serum creatinine and second progression to end-stage renal disease (ESRD) requiring either dialysis or renal transplantation. The baseline renal function characteristics as estimated by serum creatinine values are available for both the entire study population 4 and broken out separately for the diabetic cohort. 5