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Antihypertensive drugs and lipids

Authors
Michael J Bloch, MD, FACP, FASH, FSVM, FNLA
Jan Basile, MD
Section Editor
George L Bakris, MD
Deputy Editors
Daniel J Sullivan, MD, MPH
John P Forman, MD, MSc

INTRODUCTION

Drug-induced changes in lipid levels may be particularly important in hypertensive patients since up to 45 percent of untreated patients with primary hypertension (formerly called "essential" hypertension) already have lipid abnormalities, such as a high low-density lipoprotein (LDL) cholesterol [1]. In addition, genetic studies in humans suggest that a predisposition for the development of both hypertension and dyslipidemia may result from the inheritance of shared genetic risk factors [2].

Treatment of hypertension can affect lipid levels, and treatment of dyslipidemia can affect blood pressure. Some antihypertensive drugs, for example, have a neutral or beneficial effect on the lipid profile while others have an adverse effect; such adverse effects are outweighed by the beneficial effects of blood pressure lowering on cardiovascular risk. In addition, lipid-lowering therapy with statins may reduce blood pressure. In general, effects of blood pressure-lowering agents on lipid levels and effects of statins on blood pressure are modest. Blood pressure lowering and lipid lowering provide independent and, at least, additive reductions in cardiovascular risk [3,4].

EFFECTS OF DIFFERENT ANTIHYPERTENSIVE AGENTS

Antihypertensive drugs with adverse effects on plasma lipid levels — Thiazide diuretics and beta blockers may adversely affect lipid levels. However, we would not avoid using these medications (if otherwise indicated) in a patient with dyslipidemia, and, similarly, we would not discontinue these medications in a patient just to improve the lipid profile [5].

Thiazide diuretics — Very high doses of thiazide diuretics (50 to 100 mg of hydrochlorothiazide or chlorthalidone in one study) produce an initial 5 to 10 percent elevation in total and low-density lipoprotein (LDL) cholesterol and a lesser increase in triglycerides [6]. The hyperlipidemic effect of thiazide diuretics is dose dependent [6,7]. Contemporary doses lead to more modest effects. As an example, there is little or no effect on lipid metabolism with a daily dose of 12.5 mg of hydrochlorothiazide or its equivalent [8], a dose that may have an antihypertensive effect nearly as great as higher doses (see "Use of thiazide diuretics in patients with primary (essential) hypertension"). In addition, 25 mg of chlorthalidone in the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) produced a slightly higher mean total cholesterol than did lisinopril or amlodipine at four years, but the mean difference was <2.5 mg/dL [9].

Beta blockers — Beta blockers are a heterogeneous class of antihypertensive medications. The effect of beta blockers on serum lipids varies with their unique pharmacologic characteristics and may be more prominent among smokers [7,10]. Many older, traditional beta blockers, both cardioselective and noncardioselective (such as atenolol, metoprolol, and propranolol), lead to a fairly modest increase in triglycerides (20 to 40 percent), a decrease in high-density lipoprotein (HDL) cholesterol (approximately 10 percent), and little effect on total cholesterol or LDL cholesterol [7,11]. By contrast, lipid levels are relatively unaffected by labetalol (a combined alpha and beta blocker) and beta blockers with intrinsic sympathomimetic activity (eg, acebutolol and pindolol) [7].

          
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Literature review current through: Nov 2017. | This topic last updated: Nov 28, 2017.
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