Is one treatment for hypertension proven to be better than another in terms of survival?

In terms of efficacy, there is no evidence that any one class of antihypertensive is superior to another at standard doses used as monotherapy. All agents reduce blood pressure by a similar amount (approximately 5–10mmHg). However, if one assesses the large outcome trials (in terms of survival) then only the diuretics are well supported in showing reduction in mortality. The beta blockers have not been shown to reduce mortality. The oft-quoted MRC trial in elderly people used atenolol and did not reduce mortality when compared to placebo.1 Indeed, cardiovascular mortality seemed to increase in the atenolol group. In the Swedish trial in elderly patients with hypertension,2 in which mortality was reduced, initial beta blockade was one of the arms of treatment, but over two thirds of patients received an added diuretic. (If the proposal is that combined treatment with beta blockade and diuretic can reduce mortality then there are indirect supporting data from the Swedish trial.) In the MRC trial in middle-aged people, propranolol had only modest effects in nonsmokers and conferred little or no benefit in smokers. Mortality was not decreased, and the trial was not powered for mortality. Nonetheless it can be convincingly argued that end points such as reduction in stroke are important and that the beta blockers have been shown to reduce the incidence of neurovascular events in several trials. By contrast there is already one good outcome study with a calcium blocker3 but no outcome studies in essential hypertension in the elderly with ACE inhibitors, nor are there any in younger age groups. In spite of the above there still remain compelling reasons to prescribe a certain class of antihypertensive agent in patients that may have additional problems. For example, one might prescribe an ACE inhibitor to those with type 1 diabetes with proteinuria, or those with hypertension and heart failure. Similarly it might be equally cogent to prescribe a calcium antagonist in systolic hypertension in the elderly.