[Drug therapy of arterial hypertension. Reflections and suggestions]

Treatment of arterial hypertension is an important part of medical care provided in industrialized countries today. When non-drug treatment turns out to be ineffective, or when hypertension levels are higher than target values, or target organ damage is ascertained, drug therapy must be started. This rationale comes from large-scale intervention trials, which have shown that the lowering of elevated blood pressure reduces cardiovascular morbidity and mortality. A logical aim in treatment of hypertension should be both to "normalize" hypertension-induced cardiovascular abnormalities and to maintain the quality of life, without undesirable influence on other cardiovascular risks. Moreover, if we could identify the major hemodynamic impairment behind increased blood pressure and correct it by an appropriate drug therapy, then we would have a satisfactory means to perform individualized treatment. Over the past years the empirical basis for the use of antihypertensive drugs has been replaced by a step-wise approach, but few attempts have been made to provide an approach that fits pathophysiological understanding. For this reason the above-mentioned step-wise approach has been found to be an uncorrected simplification of antihypertensive care. Also, the use of more recent drugs (calcium channel blockers, ACE-inhibitors and serotonin-receptor blockers) as an alternative to beta-blockers and diuretics in first step therapy, has further contributed to the abandonment of the step-wise approach. The different groups of antihypertensive agents are examined with reference to their mechanism of action, pharmacokinetics, indications, and desirable and untoward effects. At present, indirect vasodilators, such as calcium-antagonists, ACE-inhibitors and serotonin-receptor blockers, alone or combined with diuretics, represent an intrinsic part of basic antihypertensive therapy. Beta-adrenoceptor antagonists remain the agents of choice when the principal therapeutic aim is to reduce the adrenergic drive. Both these drugs and direct vasodilators or alpha-adrenoceptor antagonists can be employed in the most severe forms of hypertension. In such cases, combined therapy (vasodilator + antiadrenergic + diuretic agents) is often used. Sublingual nifedipine and intravenous diazoxide or sodium nitroprusside are the drugs of choice for the hypertensive crisis. The use of most of the central or peripheral sympatholytic agents has generally been abandoned. Finally, beta-blockers and calcium-antagonists have been shown to have a secure place in the management of ischemic heart disease complicating arterial hypertension. In this condition captopril also appears to be useful.