[Systolic, diastolic and pulse pressure: therapeutic options]

It is now universally accepted that antihypertensive therapy reduces cardiovascular morbidity and mortality both in young and older patients. The clinical relevance of the systolic, diastolic and pulse pressure as independent risk factors is well recognized. The reduction of cardiovascular morbidity and mortality in hypertensive patients is the main therapeutic goal. There is substantial agreement on the treatment of individual risk factors and associated clinical conditions, but the best drug therapy for systolic and diastolic hypertension and/or high pulse pressure is still controversial. The recommendations of the JNC VI are that diuretics or beta-blockers be used as first-step drug therapies. The WHO-ISH guidelines recognize calcium antagonists, ACE-inhibitors, alpha-blockers and angiotensin II receptor antagonists as first-step drug therapies together with diuretics and beta-blockers. All these drugs have a similar hypotensive potential and reduce cardiovascular risk, but with noticeable differences in tolerability and side effects. It has long been demonstrated that diuretics and beta-blockers significantly reduce the cardiovascular risk, but their side effects can be relevant. ACE-inhibitors have proved to be efficacious in hypertensive patients with chronic heart failure and diabetes. Calcium antagonists are useful in the prevention of stroke but results in patients at high risk of coronary artery disease and heart failure are controversial. Alpha-blockers have proved to be unsafe in patients with heart failure but showed beneficial effects in young patients with diastolic hypertension. Angiotensin II receptor antagonists have proved to be safe and efficient but their advantages in comparison to other drugs need to be confirmed.