With regard to prevention of the cardiovascular consequences of uncontrolled hypertension, NICE concluded that: ACEIs confer a decreased relative risk of diabetes and heart failure in comparison to CCB; CCBs and thiazide diuretics are better at decreasing the risk of stroke than ACEI; AIIAs decrease the relative risk of stroke
and diabetes in comparison to beta-blockers; and CCBs are better at selleckchem decreasing the risk of myocardial infarct than AIIA. NICE also considered the evidence that there are ethnic differences in the efficacy of some antihypertensive medications, as black patients gain lower benefit from ACEIs and beta-blockers than other ethnic groups.[55] The genetic reasons underlying this ethnic difference in drug response are not
yet fully understood,[56–58] although the difference may be consequent to single nucleotide polymorphisms (SNPs) of the gene encoding for the enzyme ACE.[59,60] It is, however, unclear whether the ethic differences in drug response are solely limited to the black African population; for example, an association has been found between ACE genotype and left-ventricular response to ACE therapy in Uzbek men[61] and the outcome of antihypertensive pharmacotherapy is significantly influenced by an ACE gene polymorphism in Brazilian postmenopausal women.[62] Other genes may also have an influence as in Chinese hypertensives an association has been made between angiotensinogen and cytochrome P450 genotype and hypotensive response to the AIIA irbesartan.[63] The current NICE guidelines Selleck Compound C for the treatment of hypertension are as follows. In hypertensive patients aged 55 or over, or black patients of any age (including both black African and black Caribbean patients, not Asian, Chinese, mixed-race,
or other ethnic groups), the first choice for initial therapy should be either a calcium-channel blocker or a thiazide-type diuretic. Offer patients over 80 years of age the same Roflumilast treatment as other patients over 55, taking account of any comorbidity and their existing burden of drug use. In hypertensive patients younger than 55, the first choice for initial therapy should be an ACE inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated). These recommendations take into account clinical efficacy, but also cost-effectiveness. Considering ‘an average’ 65-year-old man or woman with an annual cardiovascular disease risk of 2%, heart-failure risk of 1% and diabetes risk of 1.1%, the most cost-effective initial drug in this group is CCBs. ACEIs and AIIAs are ruled out because it is deemed that treating some patients with diuretics and the remainder with CCBs would be cheaper and more effective than using ACEIs or AIIAs.