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The need for evidence in hypertension management: historical perspective

Mahmood A Moawad1

  • 1Internal Medicine Section, King Faisal Specialist Hospital & Research Centre, Department of Medicine, Riyadh, Saudi Arabia. moawad@kfshrc.edu.sa

Annals of Saudi Medicine
|November 8, 2005
PubMed

Insights

Diuretics remain the preferred initial treatment for hypertension, yet many clinicians overlook this guideline. Adhering to recommendations for thiazide-diuretics can significantly reduce global hypertension treatment costs.

Area of Science:

  • Cardiology
  • Pharmacology
  • Public Health

Background:

  • The National Heart, Lung, and Blood Institute introduced algorithmic hypertension treatment in 1973, establishing the stepped-care approach.
  • Initial recommendations favored diuretics, evolving through Joint National Committee (JNC) reports to include beta-blockers, calcium channel blockers (CCBs), and angiotensin-converting enzyme (ACE) inhibitors.
  • Despite evolving guidelines and resolved safety concerns with newer drug classes, thiazide-diuretics are consistently recommended as preferred initial therapy for hypertension.

Purpose of the Study:

  • To review the historical evolution of hypertension treatment guidelines.
  • To highlight the persistent recommendation for thiazide-diuretics as first-line therapy.
  • To examine the discrepancy between guideline recommendations and clinical practice in hypertension management.

Main Methods:

  • Historical review of JNC reports and international hypertension guidelines.
  • Analysis of drug class recommendations for initial antihypertensive therapy.
  • Discussion of the J-curve hypothesis and its impact on treatment thresholds.
  • Examination of adherence to guideline recommendations in clinical practice.

Main Results:

  • Diuretics were initially recommended, with subsequent guidelines expanding options but often retaining diuretics or beta-blockers as preferred initial agents.
  • Safety concerns with ACE inhibitors and CCBs have largely been addressed.
  • Despite evidence supporting the "lower the blood pressure the better" concept, especially in certain conditions, and consistent recommendations for thiazide-diuretics, many clinicians do not follow these guidelines.
  • Non-adherence to preferred initial therapy contributes significantly to global hypertension treatment costs.

Conclusions:

  • Thiazide-diuretics are recommended as the preferred initial pharmacologic treatment for hypertension.
  • Clinical practice often deviates from established guidelines, potentially increasing healthcare costs.
  • Further efforts are needed to ensure adherence to evidence-based hypertension treatment protocols.

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