Your Fluid Pill Choice Matters!
High blood pressure has the single largest impact on cardiovascular disease of any other condition. Hypertension is one of the most common causes of a primary care office visit. Getting hypertension control right is therefore a critical issue. Some have argued that chlorthalidone is a more effective medication for high blood pressure than hydrochlorothiazide (HCTZ), but that presents a problem. Hydrochlorothiazide is prescribed much more frequently than chlorthalidone and it is the fluid pill present in most combination medications for high blood pressure. For example, lisinopril/HCTZ is available from Walmart for $4 a month. That is a lot of high blood pressure punch for very little money. A recent assessment in the real world actually points to HCTZ as a better choice.
More recent studies show that HCTZ is equivalent to chlorthalidone in lowering the risk of heart attack and stroke, but chlorthalidone use is associated with a higher risk of kidney function decline, cardiovascular events, and low potassium levels in the blood. The low potassium levels are by far the most important. Low potassium is present in over twenty percent of hospitalized patients. These patients have a mortality rate ten times that of the rest of the hospitalized population. More people die because patients with decreased potassium are five times as likely to have ventricular fibrillation which is a heart rhythm problem that is frequently fatal. These patients also develop atrial fibrillation more frequently. Spironolactone causes potassium retention, and it is a green box intervention (see upper right corner of diagram) that reduces oxidants, mTOR activation, and AMPK deactivation to prolong healthy life. When combined with HCTZ it further reduces the likelihood of low potassium and dramatically improves blood pressure control. That is the safest and most effective path. At higher doses, eplerenone should be used in men.