To the Editor: The authors of The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)1 reported that lisinopril, amlodipine, and chlorthalidone were associated with similar 5-year risks of cardiac death or nonfatal myocardial infarction among patients with hypertension. However, chlorthalidone was more effective than lisinopril or amlodipine in preventing the development of heart failure. Chlorthalidone was also more effective than lisinopril in preventing combined coronary vascular disease (CVD) and stroke.
One of the unique features of ALLHAT is its sample of high-risk patients; more than half the patients had preexisting atherosclerotic CVD. This prevalence is considerably higher than in other recent clinical trials of hypertension such as Systolic Hypertension in the Elderly Program (SHEP), Systolic Hypertension in Europe (Syst-Eur) study, Swedish Trial in Old Patients with Hypertension-2 (STOP Hypertension-2), and Losartan Intervention For Endpoint reduction in hypertension study (LIFE).2 - 5
In patients with known CVD, one of the most important prognostic factors is left ventricular ejection fraction, although adequate blood pressure control is also paramount in hypertensive patients with left ventricular hypertrophy. Given the high prevalence of CVD in ALLHAT, the confounding effect of baseline ejection fraction on the primary and secondary end points may have been significant. In particular, it would be useful to know how well chlorthalidone prevented the development of heart failure independent of baseline ejection fraction. Although the authors did assess for history of myocardial infarction and coronary revascularization, ejection fraction can vary widely among such patients. Thus, a subanalysis of the results stratified by left ventricular ejection fraction would provide important clinical guidance.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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