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Important Messages from The
Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
(ALLHAT) |
(.pdf) |
ALLHAT, a randomized, double-blind,
multi-center, clinical trial sponsored by the National Heart Lung and Blood
Institute, was designed to determine whether the occurrence of CHD is lower for
high-risk hypertensive patients treated with a CCB (amlodipine), an ACEI (lisinopril), or an alpha blocker (doxazosin), each compared with diuretic treatment (chlorthalidone). A
lipid-lowering subtrial was designed to determine whether lowering cholesterol
with an HMG Co-A reductase inhibitor (pravastatin) compared with usual care
reduced mortality in a moderately hypercholesterolemic subset of participants.
ALLHAT was the largest antihypertensive trial and the second largest
lipid-lowering trial and included large numbers of patients over age 65, women,
African-Americans and patients with diabetes, treated largely in community
practice settings.
Antihypertensive Trial – 42,418 participants
♥ Because of the superiority of thiazide-type diuretics in preventing one or more major forms of CVD and their lower cost, they should be
the drugs of choice for first-step antihypertensive therapy.
♥ For the patient who cannot take a diuretic (which should be an unusual circumstance), CCB’s and ACEI’s may be considered.
♥ Most hypertensive patients require more than one drug. Diuretics should generally be part of the
antihypertensive regimen. Lifestyle advice should also be provided.
Lipid Trial – 10,355 participants
♥ ALLHAT pravastatin and usual care groups both attained
substantial cholesterol reductions, resulting in a relatively modest
cholesterol difference between them.
♥ Accordingly, ALLHAT
found only a small decrease in CVD event rates (nonsignificant) for pravastatin
compared with usual care and no difference in mortality.
♥ The study results do not alter current cholesterol treatment guidelines, which are based on a series of clinical trials with larger
cholesterol reductions than that observed in ALLHAT. Thus, cholesterol lowering
by lifestyle changes and drug treatment is recommended to reduce CVD morbidity
and mortality.
Reference: JAMA, Volume 288. December 18, 2002.
Visit ALLHAT’s website at: www.allhat.org
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Risk
Stratification and Treatment * 1
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BP Stages (mm Hg)
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Risk Group A (No Risk Factors, No TOD/CCD) †
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Risk Group B (1+
Risk Factors, Not Including Diabetes; No TOD/CCD)
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Risk Group C
(TOD/CCD and/or Diabetes)
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High-normal(130-139 / 85-89)
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LSM
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LSM
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Drug
therapy §
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Stage 1(140-159 / 90-99)
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LSM (up to 12 months)
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LSM
(up to 6 months) ‡
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Drug
therapy
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Stages 2 & 3(≥160 / ≥100)
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Drug therapy
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Drug
therapy
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Drug
therapy
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* Lifestyle modification (LSM) should be adjunctive therapy for all patients recommended for pharmacologic therapy.
† Major risk factors: smoking, dyslipidemia, diabetes, age >60, men, postmenopausal women,
family history. TOD/CCD indicates target
organ disease / clinical cardiovascular disease: LVH,
angina/prior MI, prior CABG, heart failure, stroke or TIA, nephropathy,
peripheral arterial disease, retinopathy.
‡ For patients with multiple risk factors, consider drugs as initial therapy plus lifestyle modifications.
§ For those with heart failure, renal insufficiency, or diabetes.
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Goal Blood Pressure:
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<140/90 mm Hg
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Except for the following:
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<130/85 mm Hg
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Diabetes; renal failure; heart failure
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<125/75 mm Hg
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Renal failure with proteinuria >1 gram / 24 hours
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1JNC 6 - Arch Intern Med 1997; 157:2413-2446.
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LDL Cholesterol Goals & Cutpoints for Therapeutic Lifestyle Changes (TLC) & Drug Therapy in Different Risk Categories. 2
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Risk Category
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LDL Goal
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Initiate TLC
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Consider Drug Therapy
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CHD or CHD Risk Equivalents (10-year risk >20%)
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<100 mg/dL
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LDL ≥100 mg/dL
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LDL ≥ 130 mg/dL (100-129 mg/dL: drug optional)
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2+ Risk Factors* (10-year risk ≤20%)
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<130 mg/dL
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LDL ≥130 mg/dL
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10-year risk 10-20%: LDL ≥130 mg/dL
10-year risk <10%: LDL ≥160 mg/dL
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0-1 Risk Factor*
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<160 mg/dL
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LDL ≥160 mg/dL
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LDL ≥190 mg/dL (160-189 mg/dL: LDL-lowering drug optional)
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* Risk factors: Cigarette smoking; BP ≥ 140 mmHg or on antihypertensive medication; HDL cholesterol <40 mg/dL; family history of premature CHD; age (men ≥45
years, women ≥55 years). [The presence of HDL cholesterol ≥60
mg/dL removes one risk factor from the total count.] Diabetes is a CHD risk equivalent.
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2Executive Summary, NCEP ATP III - JAMA 2001;285:2486-2497.
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