• Ran Abuhasira, Nitzan Burrack, Adi Turjeman, Yonatan Shneor Patt, Leonard Leibovici, and Alon Grossman.
• Department of Internal Medicine B, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel; Clinical Research Center, Soroka University Medical Center, Be'er Sheva, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel. Electronic address: ranabu@post.bgu.ac.il.
• Am. J. Med. 2024 Oct 17.

BackgroundThe best first-line monotherapy for hypertension remains uncertain, as current guidelines suggest that thiazides, angiotensin-converting enzyme inhibitors (ACEis), angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) are appropriate in the absence of specific comorbidities. We aimed to compare the outcomes of first-line antihypertensive classes in a real-life setting with a long follow-up period.MethodsThis nationwide retrospective new-user cohort study included patients insured by the largest health maintenance organization in Israel. We included patients with a new diagnosis of hypertension between 2008 and 2021 who initiated treatment with a single first-line drug for hypertension. Outcomes were assessed with and without propensity score matching for confounding factors. The primary composite outcome was the first occurrence of myocardial infarction (MI), acute coronary syndrome (ACS), stroke, or heart failure (HF).ResultsA total of 97,639 patients initiated antihypertensive treatment with a single drug as first-line therapy. The most commonly prescribed class was ACEis/ARBs (66,717, 68.3%), followed by CCBs (15,922, 16.3%), beta-blockers (BBs, 12,869, 13.2%), and thiazides (2,131, 2.2%). For the primary outcome, the hazard ratios (HRs) for BBs, CCBs, and ACEis/ARBs were 1.44 (95% CI 1.25-1.66), 1.10 (95% CI 0.96-1.27), and 1.13 (95% CI 0.99-1.29), respectively, when compared to thiazides.ConclusionWhen initiating pharmacotherapy for hypertension with a single drug, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers were associated with similar risk of MI, ACS, stroke, or HF when compared to thiazides, while beta-blockers were associated with increased risk.Copyright © 2024 Elsevier Inc. All rights reserved.

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