Individualized Therapy of Hypertension:

To the Editor: The recent publication of the Blood Pressure Lowering Arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT- BPLA) has again occasioned a flurry of media pronouncements and editorials contending that now the truth is known and that "newer" therapies are more effective than "old" therapies for hypertension—-blockers and diuretics. A similar flurry of media pronouncements, but in the opposite direction, was trum- peted after the publication of the Antihypertensive and Lipid- Lowering treatment to prevent Heart Attack Trial (ALLHAT), which showed that diuretics were "the best" therapy for hyper- tension. Largely unnoticed amid all this fuss was the second Australian National Blood Pressure study (ANBP2), which followed closely on the heels of the ALLHAT trial, and, like ASCOT-BPLA, also showed that angiotensin-converting en- zyme inhibitors were better than diuretics. So what are these trials trying to tell us? The fundamental fallacy underlying all this nonsense is the assumption that all patients are the same and therefore that there exists a single "best therapy" for all hypertensive patients. We should know better. It has been clear for many years that patients with African ancestors, on average, had lower levels of plasma renin than did patients without African ancestors and that patients with African ancestors responded better to diuretics.1 It has also been clear for many years that measuring plasma renin is very helpful in the management of resistant hypertension. As pointed out by the authors of ANBP2, "In ALLHAT, 32% of the patients were non-Hispanic blacks, 16% were Hispanics, and 47% were non- Hispanic whites, whereas in ANBP2, almost the entire study population was white (95%)" (and less than 2% had African ancestors (personal communication, Dr Lindon Wing, 2003)). In ASCOT-BPLA, only 5% of the subjects were "ethnic minorities: mainly South Asian or Afro-Caribbean"; only 2.4% had African ancestors (personal communication, Dr Neil Poulter, 2005). Thus, it seems that there is no mystery. Although patients with African ancestors made up only 1% of our hypertension clinic population, they accounted for 40% of our patients who needed adrenalectomy for primary hyperaldo- steronism.2 Low-renin hypertension accounts for an important proportion of resistant hypertension in hypertension clinics around the world.3,4