Amlodipine or lisinopril was not better than chlorthalidone for reducing CVD risk in hypertensive black or nonblack patients.

In black or nonblack patients with hyperten-sion, is amlodipine or lisinopril better than chlorthalidone for reducing cardiovascular disease (CVD)? Design: Randomized controlled trial (Anti-hypertensive and Lipid-lowering Treatment to Prevent Heart Attack Trial [ALLHAT]). Patients: 33 357 black and nonblack patients ≥ 55 years of age (mean age 67 y, 35% black, 53% men overall, 54% women among blacks) who had untreated or treated hyper-tension with ≥ 1 additional risk factor for coronary heart disease (CHD), including left ventricular (LV) hypertrophy, type 2 diabetes mellitus, current smoker, high-density lipo-protein cholesterol level < 0.9 mmol/L (35 mg/dL), and myocardial infarction (MI) or stroke in the previous 6 months. Patients with treated symptomatic heart failure (HF) or LV ejection fraction < 35% were excluded. Intervention: Chlorthalidone, 12.5 to 25 mg/d (n = 15 255); amlodipine, 2.5 to 10 mg/d (n = 9048); or lisinopril, 10 to 40 mg/d (n = 9054). Outcomes: Composite endpoint of fatal CHD and nonfatal MI. Secondary outcomes included all-cause mortality, fatal and non-fatal stroke, combined CHD, and combined CVD. Patient follow-up: 97% (intention-to-treat analysis). Overall, fewer blacks than nonblacks had the composite endpoint (9.7% vs 12.3%), combined CHD (15.9% vs 22.5%), and combined CVD (28.4% vs 33.7%) (P for all interactions < 0.001). Blacks had higher rates of stroke (6.5% vs 5.3%, P < 0.001), end-stage renal disease (2.6% vs 1.5%, P < 0.001), and overall mortality (17.7% vs 16.8%, P = 0.003) than nonblacks. The 3 treatment groups did not differ for the composite endpoint in either racial subgroup (Table). In blacks or nonblacks, no difference was found between amlodipine and chlorthalidone for any secondary outcomes except for HF (relative risk [RR] for In black or nonblack patients with hyperten-sion, amlodipine or lisinopril was not better than chlorthalidone for reducing cardiovascu-lar disease. Chlorthalidone was associated with a lower risk for heart failure than amlodipine or linisopril in either racial subgroup. ©ACP 63 C o m m e n t a r y In this planned substudy of the ALLHAT trial (1), Wright and colleagues examined whether CVD outcomes differed between black and nonblack patients who were started on 1 of 3 different classes of antihypertensive agents. Confirming the main trial's results, initial treatment with either amlodipine or lisinopril was not found to be superior to chlorthalidone in either racial group. In blacks, blood pressure (BP) was lowered by all 3 drugs, although less so by lisinopril, as …