In the 1970s and 1980s it was established that lowering elevated blood pressure (BP) reduced the often devastating cardiovascular complications of hypertension. A large number of anti-hypertensive agents are now on the market. In addition to their BP-lowering potential, these drugs have multiple mechanisms of action, which might add to or subtract from the benefit of BP lowering per se. The most important question today in the field of hypertension is, "Does it matter which antihypertensive drug is prescribed?" In addition to potential differences between these drugs in terms of health benefits to patients, their costs vary up to 20-fold. Thus, ALLHAT adressed very important questions from clinical, scientific and societal perspectives.

ALLHAT documented that a generic diuretic (chlorthalidone) compared with branded newer drugs, a calcium channel blocker (amlodipine) and an ACE inhibitor (lisinopril), was unsurpassed in terms of BP lowering and drug compliance over five years and, in addition, was superior to the 10 to 20 times more expensive newer drugs in reducing one or more of the cardiovascular complications. Thus, ALLHAT confirmed that the costly new agents offered "no added value." This finding has major implications for patients and for payers of prescription drugs.

ALLHAT showed that older and much less expensive drugs for the treatment of high BP (diuretics or so-called water pills) are more effective than the newer more expensive ones. Therefore, a diuretic should be the first-line drug for the treatment of most patients with hypertension and be a part of most drug combinations. Treated patients who are not receiving a diuretic alone or in combination with another drug should ask their physicians one very important question—why?

I became involved in this research due to my interest in public health. Hypertension is one of the most important public health issues in the US today—affecting about 60 million people nationwide. On the one hand, there is an enormous undertreatment of hypertension. On the other hand, there is a massive overutilization of costly antihypertensive drugs that in fact offer no real added value to the treatment of hypertension. We will all need to work together if we are to both reduce the risks to good health as well as the financial burden attached to the treatment for hypertension.