Congestive heart failure was not a prespecified end point in ALLHAT. Therefore, the science pertaining to this outcome is even softer than that pertaining to the prespecified secondary end points. The excessive attention congestive heart failure received is inappropriate and may be related to the inherent bias of some of the ALLHAT investigators. We should also remember that no other clinical end point is as difficult to objectively diagnose. In INSIGHT (International Nifedipine once-daily Study—Intervention as a Goal in Hypertension Treatment), unlike in ALLHAT, all end points were verified systematically by an end point committee, and the diagnosis of congestive heart failure decreased by a stunning 57% with reclassification (1). In ALLHAT, all the physician-investigators had to do was mark a box, and only a small fraction of all end points were verified.

Numerous studies, including ALLHAT, have shown that ACE inhibitors and, to a lesser extent, calcium antagonists decrease the risk for new-onset diabetes, whereas thiazide diuretics, ß-blockers, and the combination of the 2 drugs seem to increase this risk. Given that the prevalence of obesity, the metabolic syndrome, and frank diabetes have doubled in the United States over the past decade, the differences in metabolic findings observed with various drug classes should not be shrugged off, as was done by the ALLHAT investigators. Angiotensin-converting enzyme inhibitors have been, are, and will remain a cornerstone for prevention of and therapy for diabetic nephropathy and congestive heart failure. I fully agree with Dr. Ahmed that although ALLHAT provides us with rock-solid data on the primary end point, that is, coronary artery disease, the soft findings pertaining to congestive heart failure should by no means form a scientific basis for depriving at-risk hypertensive patients of treatment with ACE inhibitors.