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In Reply: Like Dr Fournier and colleagues, we are uncertain about the possibility of class-specific differences in clinical outcomes (such as stroke or myocardial infarction) among antihypertensive drugs. Although debate continues about their relative efficacies, thiazide diuretics, -blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and long-acting dihydropyridine calcium channel blockers have been shown to reduce the risk of stroke. However, given the results of the recently published ALLHAT trial¹ and the relative costs of the various agents, we believe that thiazide diuretics remain the agents of first choice in hypertensive patients for the primary prevention of cardiovascular and cerebrovascular disease. Furthermore, a meta-regression of 27 antihypertensive drug trials found that the reductions in stroke (as well as other cardiovascular end points) from antihypertensive therapy observed in these trials could be explained by the achieved differences in SBP.² Of note, this meta-regression included the CAPPP trial that Fournier et al mention.

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Sharon E. Straus, MD, FRCPC
Department of Medicine
University of Toronto
Toronto, Ontario

Finlay A. McAlister, MD, FRCPC; Sumit R. Majumdar, MD, FRCPC
Division of General Internal Medicine
University of Alberta
Edmonton

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