Diuretic Treatment of Hypertension

A lthough thiazide and thiazide-like diuretics are indispensable drugs in the treatment of hypertension, their role as first-line or even second-line drugs is a provoking debate. The European Society of Cardiology/ European Society of Hypertension (ESC/ ESH) guidelines recommend that thiazide diuretics should be considered as suitable as b-blockers, calcium antagonists, ACE inhibitors, and angiotensin receptor blockers for the initiation and maintenance of antihypertensive treatment (1). Another European position, endorsed by the British Hypertension Society, is that diuretics and calcium channel blockers should be first-line drugs in hypertensive patients aged $55 years or black patients of any age, whereas ACE inhibitors (or angiotensin receptor blockers in the case of intolerance to ACE inhibitors) should be first-line drugs in hypertensive patients younger than 55 years of age (http://nice.org.uk/ CG034guidance). The Seventh Report of the Joint National Committee (JNCVII) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends that thiazide diuretics should be preferred drugs in “most” hypertensive patients, either alone or combined with drugs from other classes (2). The present review does not intend to negate the important role of diuretics in certain groups of patients (blacks, saltsensitive patients, concomitant heart failure) or to underestimate their role in multiple-drug combinations in patients with resistant hypertension. The main argument that will be discussed is the place of diuretics as first-line drugs or addon drugs in the context of the available antihypertensive armamentarium. The pro side of the controversy will argue that diuretics should remain the preferred drugs for initial treatment in many hypertensive patients, whereas the cons side will contend that emerging evidence from outcome-based studies is casting doubt on the role of these drugs as first-line and even second-line antihypertensive treatment.