Diuretics and risk of sudden death in hypertension--evidence and potential implications

Randomized trials have produced solid evidence that non potassium-sparing diuretic therapy in hypertension is beneficial, but the controversy regarding the possibility that these drugs may increase the risk of sudden death in some patients continues. Although few sudden deaths were reported in the trials, findings indicate that an excess risk of sudden death in users of these diuretics exists (pooled risk ratio 1.5; 95% CI 1.1-2.0). Two recent case-control studies provide consistent evidence that non potassium-sparing diuretics are associated with a twofold risk of sudden death compared to potassium-sparing diuretic therapy. It is estimated that among the 400,000 men and 1,000,000 women treated for hypertension in the Netherlands, such as excess risk would lead to respectively 96 and 34 cases of sudden death. We conclude that the available evidence strongly suggests that hypertensive patients on non potassium-sparing diuretic therapy are at an increased risk of sudden death. Concomitant prescription of potassium-sparing diuretic agents should be considered in these patients.