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Antihypertensive drugs and lipids

Author
Norman M Kaplan, MD
Section Editor
George L Bakris, MD
Deputy Editor
John P Forman, MD, MSc

INTRODUCTION

Early trials on the treatment of hypertension based upon high doses of diuretics or beta blockers demonstrated a significant reduction in stroke but a less prominent decline in the incidence of coronary heart disease [1]. This relative lack of coronary benefit may have been related to the adverse effect of these antihypertensive agents on plasma lipids [2] since even small elevations in serum cholesterol may significantly increase coronary risk, particularly in patients with underlying hypertension [3]. However, when another analysis was published in 2003, which included multiple studies with lower doses of diuretics and newer agents, a greater reduction of coronary heart disease was documented [4].

Drug-induced changes in lipid levels may be particularly important in hypertensives since up to 40 percent of untreated patients with primary hypertension (formerly called "essential" hypertension) already have lipid abnormalities, such as a high LDL-cholesterol and a low HDL-cholesterol [5]. Obesity, diabetes, or alcohol abuse may be responsible for this association. 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 [6]. (See "Prehypertension".)

It is important to appreciate, however, that the potential adverse effect of antihypertensive therapy on lipid metabolism does not mean that such therapy should be withheld. A report from the Helsinki Heart Study, for example, demonstrated that effectively treating hypertension in hypertensive, dyslipidemic men (primarily with diuretics and beta blockers) reduced the risk of coronary events by more than 50 percent when compared to those with persistent hypertension [7].

Treatment of dyslipidemia with HMG CoA reductase inhibitors (statins) may independently lower blood pressure [8,9]. This was best shown by the UCSD Statin study, which was a randomized placebo-controlled trial that included 973 subjects and examined the effect of either 20 mg of simvastatin, 40 mg of pravastatin or placebo on blood pressure at six months [10]. Both statins modestly reduced systolic and diastolic blood pressure by 2.2 and 2.4, respectively. Given that the beneficial actions of antihypertensive agents and statins are not adversely affected (and may be enhanced) with concurrent use, hypertension and dyslipidemia can be effectively treated by administering both classes of drugs.

EFFECTS OF DIFFERENT ANTIHYPERTENSIVE AGENTS

The effects of the different classes of antihypertensive drugs on plasma lipid levels can be summarized as follows:

        

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Literature review current through: Nov 2016. | This topic last updated: Mon Apr 27 00:00:00 GMT 2015.
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References
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  1. Psaty BM, Smith NL, Siscovick DS, et al. Health outcomes associated with antihypertensive therapies used as first-line agents. A systematic review and meta-analysis. JAMA 1997; 277:739.
  2. Kasiske BL, Ma JZ, Kalil RS, Louis TA. Effects of antihypertensive therapy on serum lipids. Ann Intern Med 1995; 122:133.
  3. McMahan CA, Gidding SS, Fayad ZA, et al. Risk scores predict atherosclerotic lesions in young people. Arch Intern Med 2005; 165:883.
  4. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 4. Effects of various classes of antihypertensive drugs--overview and meta-analyses. J Hypertens 2015; 33:195.
  5. Goode GK, Miller JP, Heagerty AM. Hyperlipidaemia, hypertension, and coronary heart disease. Lancet 1995; 345:362.
  6. Williams RR, Hunt SC, Hopkins PN, et al. Familial dyslipidemic hypertension. Evidence from 58 Utah families for a syndrome present in approximately 12% of patients with essential hypertension. JAMA 1988; 259:3579.
  7. Mänttäri M, Tenkanen L, Manninen V, et al. Antihypertensive therapy in dyslipidemic men. Effects on coronary heart disease incidence and total mortality. Hypertension 1995; 25:47.
  8. Spósito AC, Mansur AP, Coelho OR, et al. Additional reduction in blood pressure after cholesterol-lowering treatment by statins (lovastatin or pravastatin) in hypercholesterolemic patients using angiotensin-converting enzyme inhibitors (enalapril or lisinopril). Am J Cardiol 1999; 83:1497.
  9. Tonolo G, Melis MG, Formato M, et al. Additive effects of Simvastatin beyond its effects on LDL cholesterol in hypertensive type 2 diabetic patients. Eur J Clin Invest 2000; 30:980.
  10. Golomb BA, Dimsdale JE, White HL, et al. Reduction in blood pressure with statins: results from the UCSD Statin Study, a randomized trial. Arch Intern Med 2008; 168:721.
  11. Reaven GM, Clinkingbeard C, Jeppesen J, et al. Comparison of the hemodynamic and metabolic effects of low-dose hydrochlorothiazide and lisinopril treatment in obese patients with high blood pressure. Am J Hypertens 1995; 8:461.
  12. Vyssoulis GP, Karpanou EA, Pitsavos CE, et al. Dyslipidemic effects of cigarette smoking on beta-blocker-induced serum lipid changes in systemic hypertension. Am J Cardiol 1991; 67:987.
  13. Giugliano D, Acampora R, Marfella R, et al. Metabolic and cardiovascular effects of carvedilol and atenolol in non-insulin-dependent diabetes mellitus and hypertension. A randomized, controlled trial. Ann Intern Med 1997; 126:955.
  14. Bakris GL, Fonseca V, Katholi RE, et al. Metabolic effects of carvedilol vs metoprolol in patients with type 2 diabetes mellitus and hypertension: a randomized controlled trial. JAMA 2004; 292:2227.
  15. Levy D, Walmsley P, Levenstein M. Principal results of the Hypertension and Lipid Trial (HALT): a multicenter study of doxazosin in patients with hypertension. Am Heart J 1996; 131:966.
  16. Weinberger MH. Influence of an angiotensin converting-enzyme inhibitor on diuretic-induced metabolic effects in hypertension. Hypertension 1983; 5:III132.
  17. Kannel WB, Carter BL. Initial drug therapy for hypertensive patients with hyperlipidemia. Am Heart J 1989; 118:1012.