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Management of hypertension and cardiovascular risk
1Brigham and Women's Hospital, Boston, Massachusetts 02115.
Insights
Lowering blood pressure in hypertension is a surrogate goal. The choice of antihypertensive medication impacts cardiovascular and metabolic health, influencing outcomes beyond blood pressure reduction.
Area of Science:
- Cardiology
- Pharmacology
- Nephrology
Background:
- Hypertension management aims to reduce associated risks, with blood pressure reduction serving as a common surrogate endpoint.
- While antihypertensive therapies have improved outcomes, their impact on atherosclerosis and coronary events is limited.
- Metabolic disturbances and electrolyte abnormalities associated with certain antihypertensive agents may contribute to adverse cardiovascular events.
Purpose of the Study:
- To review the therapeutic implications of using blood pressure reduction as a surrogate endpoint in hypertension.
- To examine the effects of new antihypertensive agents on clinical outcomes, mechanisms, and patient-specific factors.
- To assess the influence of antihypertensive selection on left ventricular hypertrophy, renal injury, and metabolic abnormalities.
Main Methods:
- Review of clinical trial data and treatment results for novel antihypertensive agents.
- Analysis of underlying mechanisms of action for various antihypertensive drug classes.
- Evaluation of the impact of antihypertensive therapy on surrogate markers and clinical endpoints.
Main Results:
- Antihypertensive therapy has shown success but minimally reduced atherosclerosis and coronary events.
- Metabolic disarray from agents like thiazides and beta-blockers may impede cardiovascular benefits.
- Left ventricular hypertrophy and renal injury progression demonstrate selective responsiveness to different antihypertensive agents.
- Obesity-associated metabolic abnormalities, like insulin resistance, are also influenced by antihypertensive agent selection.
Conclusions:
- The choice of antihypertensive medication significantly influences cardiovascular risk beyond blood pressure control.
- Metabolic side effects and specific organ responses necessitate careful agent selection in hypertension management.
- Addressing metabolic abnormalities, common in obese and non-obese hypertensive patients, is crucial and agent-dependent.
Abstract:
Blood pressure reduction in hypertensive patients is a surrogate for the real therapeutic goal of reducing the risks consequent to hypertension. This surrogate is convenient but its use may have important therapeutic implications. Results of treatment with new antihypertensive agents, data from clinical trials, and insights into underlying mechanisms are reviewed. The overall success of antihypertensive therapy has been undeniable, but has reduced minimally the frequency of atherosclerosis and coronary events; metabolic disarray resulting from the agents used, especially thiazides and beta blockers, may have contributed to this. Electrolyte abnormalities predispose to malignant arrhythmias and sudden death during myocardial infarction. Left ventricular hypertrophy, a chief risk factor for coronary events, arrhythmias, and heart failure, responds selectively to antihypertensive agents. Similarly, progression of renal injury may be sensitive to the agents used. Obesity and hypertension frequently coexist. Evidence is growing that atherogenic abnormalities common in obese patients, such as insulin resistance, also occur in the nonobese patient and are sensitive to the antihypertensive agent selected.