ABC | Volume 112, Nº1, January 2019

Brief Communication Bertoluci et al Diuretics and losartan in stage I hypertension Arq Bras Cardiol. 2019; 112(1):87-90 Table 1 – Baseline clinical and demographic characteristics of participants by treatment group PREVER-treatment study Echo substudy Diuretics (n = 333) Losartan (n = 322) Diuretics (n = 56) Losartan (n = 54) Sex (male) 167 (50.2) 167 (51.9) 34 (60.7) 28 (51.9) Age (years) 53.9 ± 8.4 54.7 ± 7.9 55.5 ± 7.6 54.1 ± 8.3 BMI (kg/m²) 29.1 ± 5.0 28.8 ± 4.7 28.5 ± 4.4 28.5 ± 4.3 SBP (mmHg) 142.6 ± 7.1 142.1 ± 6.5 142.2 ± 8.2 139.4 ± 6.0 DBP (mmHg) 89.7 ± 6.3 89.4 ± 6.1 90.6 ± 5.9 90.2 ± 5.6 Diuretics: chlorthalidone/amiloride; BMI: body mass index; SBP: systolic blood pressure; DBP: diastolic blood pressure. Data are expressed as mean ± SD or number (%). chosen studies using intraclass correlation coefficient, and varied between 0.99 and 0.67, with the lowest reproducibility found for the posterior wall thickness measurement. Results Of the 655 participants of the PREVER-treatment study, 230 participants from Hospital de Clínicas de Porto Alegre center were invited to participate in the echocardiographic evaluation, of which 133 participants were willing to participate, and 110 underwent the echocardiograms at baseline and after 18 months of follow-up. Baseline demographic and clinical characteristics are shown in Table 1. Systolic blood pressure (SPB) was lower in the losartan group than in the main study, but it was similar between patients receiving diuretics and losartan who underwent echocardiograms. All other baseline characteristics were similar between the treatment groups and the main study group, including previous use of antihypertensive drug (diuretics: 71.4%, losartan: 65%, p = 0.47). As shown in Table 2, there was no significant difference between the treatment groups regarding the final SBP. There was a similar proportion of patients receiving full dose of amlodipine (10 mg per day) after 18 months of follow-up in both treatment groups (5,3% in diuretics group, 9,2% in losartan group, p = 0.43). Baseline echocardiographic parameters were similar among the groups (Table 2), except for LA volume index (LAVI) which was higher in the losartan group (28.2 ± 7.8 mL/m² vs 25.4 ± 6.5 mL/m², p < 0.05). After 18 months of treatment, there was a significant reduction in interventricular septal thickness (IVST), posterior wall thickness (PWT) and relative wall thickness (RWT), with a significant rise in E-wave deceleration time (EDT) in the diuretics group; in the losartan group, there was a significant reduction in LA volume index (LAVI), LVM index (LVMI), IVST, PWT and RWT (Table 2). After adjustment for mean blood pressure variation, baseline echocardiographic parameter and time between randomization and echocardiographic examination, individuals in the losartan group had a greater interventricular septal thickness reduction (-0.7 ± 1.1 mm vs . -0.3 ± 1.2 mm; adjusted difference: 0.6 mm; p=0.009). However, this reduction was not sufficient to translate into differences in geometric patterns or diastolic function parameters between the treatment groups. Discussion This study shows that, in stage I hypertension, LV mass and LA size reductions, and changes in diastolic function parameters were similar with chlorthalidone/amiloride or with losartan treatment for 18 months. Detection of target-organ damage is important for an adequate estimate of prognosis of the hypertensive patient. Increased LV mass and hypertrophy independently predict cardiovascular events. Despite concerns about echocardiographic variability, 10 it is the first-line imaging study for LV mass evaluation. In our study, to increase reproducibility of measurements, all studies were blindly read to visit and treatment allocation, and the paired analysis of data allowed the measurement of the intrinsic variation for each participant. Two large studies directly compared different antihypertensive drug classes. The TOMHS study, in the pre-angiotensin receptor antagonist (ARB) era, evaluated 844 patients with stage I hypertension randomized for non‑pharmacological treatment and chlorthalidone, acebutolol, amlodipine, enalapril, doxazosin or placebo. 11 Only chlorthalidone promoted regression of LVH compared to placebo in 12 months (-4.8g vs -18.2g; p = 0.04), with no difference observed in 48 months. It is important to note that, during follow-up, 33% of patients on the placebo group were prescribed active medication. The LIFE substudy evaluated 960 patients with a higher SBP (160-200 mmHg) randomized for losartan or atenolol. 12 After 5 years, LVM showed greater reduction with losartan than with atenolol (-21.7 g vs -17.7 g; p = 0.01), although BP reduction was similar. In this study, LVM reduction was also more pronounced during the first 12 months of treatment. It should be noted that more patients on the losartan group were also using hydrochlorothiazide. As far as we know, only one study directly compared diuretic (hydrochlorothiazide) and ARB (telmisartan) use in 69 patients with DBP of 90-114 mmHg, showing a higher reduction of LVM estimated by three-dimensional echocardiography with telmisartan (16 g versus 4 g in 12 months). 13 It is noteworthy that ARBwas used at amaximumdose and the diuretic at a lowdose. The results of our study are in line with the findings of a meta-analysis 5 summarizing randomized comparative studies of antihypertensive treatment on LV mass regression in patients with stage II hypertension. There was less LV mass regression with beta-blockers, while diuretics, calcium 88