Myocardial Infarction Associated With Antihypertensive Drug Therapy-Reply

In Reply.  —Dr Blandino has suggested that "miscommunication" of nondefinitive data disparaged the use of diuretics initially. Nobody would disagree that reliable evidence of net benefits of drug treatment of mild to moderate hypertension on subsequent cardiovascular mortality, stroke, and myocardial infarction were derived from randomized trials primarily testing diuretics and β-blockers.^1-3 However, the stroke benefit is virtually identical to that predicted from meta-analysis of observational studies, whereas for myocardial infarction the benefit is about one-half to two-thirds that predicted. Both chance and a delayed effect on atherogenesis may explain this shortfall, but another plausible hypothesis is possible elevations of low-density lipoprotein cholesterol by about 5%, which could increase risk of myocardial infarction by 15%. Thus, randomized trial data are needed to provide reliable evidence on the balance of risks and benefits of all these agents.Dr Blandino and Drs Cooper and Freeman question the degree of clinical certainty