Letter to the Editor Hypertension, Has Treatment a ` la Carte Arrived? To the Editor: The majority of patients with hypertension need at least 2 antihypertensive agents to achieve blood pressure (BP) goals. After the Avoiding Cardiovascular Events in Combination Therapy in Patients Living With Systolic Hypertension (ACCOMPLISH) trial, 1 in which, despite a nearly similar BP reduction, the fixed combination benazepril plus amlodipine reduced the primary end point by 19.6% when compared with the fixed combination benazepril plus hydrochlorothiazide in a high-risk hypertensive population, many physicians thought that diuretics were inferior to prevent cardiac events in the whole hypertensive population. However, hospitalizations for heart failure (HF) were not included in the primary end point or in the main secondary end point. In addition, 60% of pa- tients in this study at baseline were persons with diabetes, and 50% were obese, and it is well known that thiazides may worsen metabolic profile. In the Telmisartan Randomised Assessment Study in ACE Intolerant Subjects With Cardiovascular Disease (TRANSCEND), 2 the addition of telmisartan to participants with diabetes and end-organ damage or cardiovascular disease did not significantly reduce the primary end point, which in- cluded cardiovascular death, myocardial infarction, stroke, or hospitalization for HF. Remarkably, the rates of hospitaliza- tions for HF were similar in both groups. How could this result have emerged? Surprisingly, although the use of diuretics was initially similar in both groups, the proportion of patients on diuretics at the end of the study was significantly higher in the placebo arm (33.7% vs 40.0%, P  0.0001). It is likely that, in some patients, diuretics were not prescribed for improving BP control but rather for treating clinical HF. Therefore, the greater use of diuretics may have decreased HF hospital admis- sions in the placebo group and obscured the benefit from telmisartan. Furthermore, diuretics may mask HF symptoms and secondarily reduce HF diagnosis. In a recent study performed by Ogunyankin et al., 3 an ag- gressive BP-lowering strategy with either calcium channel blockers or diuretics was associated with a significant improve- ment of left ventricular diastolic function; however, there was a trend toward greater diastolic-function improvement in the diuretic-based subgroup. These findings have been confirmed in a recent meta-analysis, which reported that diuretics repre- sent the most effective class of drugs in preventing HF in hy- pertensive patients, followed by renin-angiotensin system in- hibitors. 4 Calcium channel blockers and -blockers were found to be less effective in HF prevention. With these data the authors concluded that diuretics and renin-angiotensin system inhibitors should be used as first-line antihypertensive therapy for HF prevention in the hypertensive population at risk to develop HF. What do these results indicate? It appears that in hyperten- sives with obesity, diabetes, or at high risk to develop diabetes, the combination of a renin-angiotensin system inhibitor plus a calcium channel blocker would be preferable, whereas in pa- tients at risk to develop HF, such as in those with ventricular dysfunction, the renin-angiotensin system inhibitor could likely be combined with a diuretic. These findings move us closer to patient-tailored, à la carte therapy for hypertension. Carlos Escobar, MD, PhD Department of Cardiology Hospital Infanta Sofia Madrid, Spain Vivencio Barrios, MD, PhD Department of Cardiology Hospital Ramón y Cajal Carretera de Colmenar Viejo km 9,100 28034, Madrid, Spain vbarriosa@meditex.es vbarrios.hrc@salud.madrid.org Disclosures The authors have no conflicts of interest to disclose. References 1. Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med 2008;359:2417-28. 2. Telmisartan Randomised Assessment Study in ACE Intolerant Subjects With Cardiovascular Disease (TRANSCEND) Investigators. Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high- risk patients intolerant to angiotensin-converting enzyme inhibitors: a ran- domised controlled trial. Lancet 2008;9644:1174-83. 3. Ogunyankin KO, Day AG. Successful treatment of hypertension accounts for improvements in markers of diastolic function: a pilot study comparing hydrochlorothiazide-based and amlodipine-based treatment strategies. Can J Cardiol 2009;25:e406-12. 4. Sciarretta S, Palano F, Tocci G, Baldini R, Volpe M. Antihypertensive treatment and development of heart failure in hypertension: a Bayesian network meta-analysis of studies in patients with hypertension and high cardiovascular risk. Arch Intern Med 2011;171:384-94. doi:10.1016/j.cjca.2011.02.004 Canadian Journal of Cardiology 27 (2011) 524.e5 www.onlinecjc.ca 0828-282X/11/$ – see front matter © 2011 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.