Patients with hypertension prescribed diuretics rather than ACE inhibitors first-line have a lower risk of myocardial infarction, stroke and hospitalisation for heart failure, a landmark review has found.

The analysis of data from 4.9 million people initiated on antihypertensive monotherapy also showed that non-dihydropyridine calcium channel blockers were significantly inferior to all other classes of blood pressure drugs.

In the systematic review, researchers drew upon real-world evidence of comparative effectiveness and safety from four countries to estimate the risk of 55 health outcomes.

Almost half of the cohort (48%) was initiated on an ACE inhibitor, 17% a thiazide or thiazide-like diuretic, 16% a dihydropyridine calcium channel blocker, 15% an angiotensin receptor blocker, and the remainder a non-dihydropyridine calcium channel blocker.