Htn rx -- hctz less good in normal wt patients

Subgroup analysis of the ACCOMPLISH trial found decreasing benefit of the benazepril/hctz combo pill vs benazepril/amlodipine combo in progressively lower BMI patients (see htn ccb better than hctz in nonobese lancet 2013 in dropbox).  So, here's the skinny...
 
Secondary analysis of 11400 pts randomized to either of the above meds being treated for systolic htn (ave around 146/80 pretreatment), with primary outcome of cardiovasc death, nonfatal MI or stroke, with results below per 1000 pt-yrs
:
        --by BMI, those on combo of benaz/amlod (average titrated dose 36/8 mg, leading to bp on treatment of approx 133/72)
                -- for normal BMI (<25):30.7
                -- for overwt (BMI bet 25 and 30): 21.9
                -- for obese (BMI>30): 18.2
        --by BMI, those on combo of benaz/hctz (average titrated dose of 36/19 mg, leading to bp on treatment of approx 134/74)
                -- for normal BMI (<25):18.2
                -- for overwt (BMI bet 25 and 30): 16.9
                -- for obese (BMI>30): 16.5
 
So, no statistically signif diff in amlod vs hctz groups for obese, but 24% dec events for overwt and 43% in normal wt.
 
This is a secondary analysis (though other studies i've sent out do suggest somewhat different pathophysiology of htn in obese pts).  I will also send out again an old email on some important (i think) htn studies -- highlightling the nice recommendations (that is, natl institute for clinical excellence in the UK), which promotes the use of calc channel blocker (ccb) as first-line med in all but those of non african-caribbean heritage younger than 55 (where ace-i is first-line), relegateing diuretics to a second-line drug (and preferring chlorthalidone over hctz).  My recent pharmacy survey is that generic amlodipine is much cheaper than nifedipine. Both ccb's also lower serum uric acid levels.

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