[Which hypertensive patient requires diuretic therapy?]

Over the last decade the role of diuretics as first-line agents for the treatment of hypertension has diminished substantially. The present review encourages the reader to reconsider the current trend for a decline in the use of these inexpensive antihypertensive drugs whose efficacy is well documented. Diuretics have been used in 16 placebo controlled studies with over 13,000 patients as first-line drugs to lower blood pressure. These drugs were shown to reduce total mortality by 11%, cerebrovascular events by 34% and coronary morbidity by 29%. The magnitude of blood pressure reduction with low-dose thiazide diuretics is comparable to that of a therapy with high-dose thiazides, without the serious metabolic side effects observed with the higher dosage. In combination with other antihypertensive agents, diuretics counteract the compensatory regulatory responses, such as volume expansion and edema formation. Moreover, it has been shown that a combination with low-dose thiazides may not only further decrease blood pressure but also reduce cerebrovascular and coronary mortality. Advantages of diuretics in the treatment of hypertension can be appreciated in special clinical conditions, for instance in patients with edema, heart failure, renal failure, nephrotic syndrome and portal hypertension. Low-dose diuretics still have a place as first-line drugs for the treatment of mild, uncomplicated essential hypertension. Moreover, as opposed to other blood pressure lowering agents, there is sufficient scientific evidence for the primary preventive effect of low-dose thiazide.