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Myocardial infarction and stroke associated with diuretic based two drug antihypertensive regimens: population based case-control study
BMJ 2010;340:c103
Inbal Boger-Megiddo, fellow trainee1, Susan R Heckbert, professor of epidemiology1, Noel S Weiss, professor of epidemiology2, Barbara McKnight, professor of biostatistics3, Curt D Furberg, professor of public health sciences4, Kerri L Wiggins, data manager and analyst1, Joseph A C Delaney, postdoctoral fellow3, David S Siscovick, professor of medicine and epidemiology1, Eric B Larson, executive director and senior investigator5, Rozenn N Lemaitre, research scientist1, Nicholas L Smith, associate professor of epidemiology1, Kenneth M Rice, assistant professor of biostatistics3, Nicole L Glazer, research scientist1, Bruce M Psaty, professor of medicine and epidemiology1
Correspondence to: B M Psaty psaty@u.washington.edu

Conclusion
Chez les patients hypertendus, l'association diurétique - Inhibiteur calqiue entraine une augmentation du risque cardiovasculaire comparé aux autres bithérapies
Un grand essai est nécessaire pour apporter une base solide pour déteminer le choix d'un second médicament chez des patients déjà traités par un diurétique.

Voir également l'étude ACCOPLISH comparant l'association IEC + ICA (bénazépril + amlodipine) à l'association IEC + Diuretique (bénazépril + hydrochlorothiazide) [Lire]

Objective
To examine the association of myocardial infarction and stroke incidence with several commonly used two drug antihypertensive treatment regimens.

Design
Population based case-control study.

Participants
Cases (n=353) were aged 30-79 years, had pharmacologically treated hypertension, and were diagnosed with a first fatal or non-fatal myocardial infarction or stroke between 1989 and 2005. Controls (n=952) were a random sample of Group Health members who had pharmacologically treated hypertension. We excluded individuals with heart failure, evidence of coronary heart disease, diabetes, or chronic kidney disease.

Exposures
One of three common two drug combinations:
  • diuretics plus ß blockers
  • diuretics plus calcium channel blockers
  • diuretics plus angiotensin converting enzyme inhibitors or angiotensin receptor blockers.
Main outcome measures
Myocardial infarction or stroke.

Results
Compared with users of diuretics plus ß blockers, users of diuretics plus calcium channel blockers had an increased risk of myocardial infarction (adjusted odds ratio (OR) 1.98, 95% confidence interval 1.37 to 2.87) but not of stroke (OR 1.02, 95% CI 0.63 to 1.64).
The risks of myocardial infarction and stroke in users of diuretics plus angiotensin converting enzyme inhibitors or angiotensin receptor blockers were slightly but not significantly lower than in users of diuretics plus ß blockers (myocardial infarction: OR 0.76, 95% CI 0.52 to 1.11; stroke: OR 0.71, 95% CI 0.46 to 1.10).

Conclusions
In patients with hypertension, diuretics plus calcium channel blockers were associated with a higher risk of myocardial infarction than other common two drug treatment regimens. A large trial of second line antihypertensive treatments in patients already on low dose diuretics is required to provide a solid basis for treatment recommendations.

© Boger-Megiddo et al 2010
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