Was it optimal to drop a diuretic as a first-line choice of drug treatment in the 2020 International Society of Hypertension Guidelines?

Figures & data

Table 1. Potential choices of add-on to angiotensin-converting enzyme inhibitor or angiotensin receptor blocker treatment in first-line combination treatment for most hypertensive patients: Dihydropyridine calcium channel blocker (CCB) or thiazide-type of diuretic for initial combination therapy? Clinical conditions and preferences discussed in 2017 American [4] and 2018 European Hypertension Guidelines [5].

Favours dihydropyridine CCB	Favours thiazide or thiazide-like diuretic such as chlorthalidone or indapamide
Metabolic syndrome	Fluid overload
Gout	Ankle edema (but not caused by CCB)
Diuretic intolerance	CCB intolerance
Patient preference	Patient preference
Left ventricular hypertrophy	High salt intake
Angina pectoris*	Unhealthy diet (high ‘junk food’ intake)
Type 2 diabetes (ACCOMPLISH data) [10]	Type 2 diabetes with salt sensitivity
Stable coronary disease	Overweight with salt sensitivity
Renal failure (ACCOMPLISH data) [11]	Renal failure with sodium retention
Chronic obstructive pulmonary disease	Hyperkalaemia
Atherosclerosis in lower limbs with	Symptomatic treatment in imminent or
claudicatio intermittens*	suspected heart failure

*Anti-ischemic properties.

Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269–1324.

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