Principles of drug therapy in hypertension

The most difficult diagnosis in medicine is the diagnosis of hypertension. Since this label encompasses many maladies both known (secondary hypertension), and the unknown, the office recording of blood pressure alone will not suffice to warrant treatment with drugs right away. There are more than 6 major guidelines in the world about the rules of the game of drug therapy in hypertension. The present preoccupation with newer drugs as first line antihypertensive drugs would ruin any economy, if the exchequer is to foot the bill. The stress in drug treatment has been the step-care mode of drug therapy where one starts with one drug in small doses, building the dose gradually, adding the next drug to get cumulative power to lower the pressure. Since the early seventies, the need to step-down therapy is being stressed wherein the doctor starts cutting down the drugs and the dosage, once he achieves the desired blood pressure levels. Diuretics and beta-blockers should be the first choice when drugs are indicated, unless there are positive indications for other drugs, or the first line drugs are contra-indicated. Routine treatment with drugs is recommended by the American JNC for people with sustained blood pressure above 140/90 mm Hg, but the British recommendations put the cut off at the pressure level of 160/100 mm Hg. Indian patients respond to very small doses in the beginning. The Hypertension Optimal Treatment (HOT) study failed to demonstrate a significant difference between the 3 randomised target blood pressure groups for the majority of cardiovascular events, although it did prove the theoretical hypothesis, that more vigorous treatment could certainly bring down the measured blood pressure to greater extent in 90% of patients I Greater importance will be given in the future for the non-pharmacological approaches, as well as to baseline blood pressure values, at which drug treatment should be started.