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From stepped care to tailored therapy.
1Department of Epidemiology and Public Health, University College and Middlesex School of Medicine, London, UK.
Journal of Human Hypertension
|December 1, 1991
Summary
The "stepped care" approach to hypertension management, initiated in 1977, has been replaced by "tailored therapy." This shift reflects evolving cardiovascular risk assessment and broader first-line drug options beyond diuretics and beta-blockers.
Area of Science:
- Cardiology
- Pharmacology
- Public Health
Background:
- The Joint National Committee introduced 'stepped care' in 1977 for hypertension management.
- Initial stepped care involved diuretics, beta-blockers, and vasodilators in sequential steps.
- Modifications occurred in the 1980s due to risk factor management and new agents.
Purpose of the Study:
- To trace the evolution of hypertension management guidelines.
- To explain the transition from 'stepped care' to 'tailored therapy'.
- To highlight the changing role of diuretics and beta-blockers in hypertension treatment.
Main Methods:
- Historical review of hypertension management guidelines.
- Analysis of the impact of evolving risk factor approaches.
- Examination of clinical trial outcomes and expert consensus.
Main Results:
- Stepped care, once internationally adopted, became less viable by 1989.
- Concerns arose from the interaction of hypertension with other coronary heart disease risks.
- Thiazides and beta-blockers showed disappointing effects on coronary heart disease events in trials.
Conclusions:
- Stepped care has been superseded by 'tailored therapy' for hypertension.
- Tailored therapy bases initial drug choice on a patient's overall cardiovascular risk profile.
- Diuretics and beta-blockers are now often considered second- or third-line agents, except in specific cases.