Analysis of treatment outcomes. Why is benefit not larger?

The benefits of antihypertensive treatment are well-known. In malignant hypertension antihypertensive therapy has markedly improved prognosis and increased 5-year survival from 0% to 75%. In addition, the incidence of this severe form of hypertension has been shown to decrease significantly in some centers. In nonmalignant hypertension prognosis is also markedly improved thanks to antihypertensive therapy, with substantial reductions in the incidence of stroke and congestive heart failure, whereas the beneficial effects against coronary heart disease are less obvious. In addition, during recent years there has been some discussion about the J-curve phenomenon. There are several conceivable explanations behind the less than optimal outcome of antihypertensive therapy. Some of these will be discussed here, e.g. the fact that hypertension-induced pathology is only partially reversible. Moreover, in several intervention studies strict normotensive blood pressures have not been obtained during treatment. In addition, some of the antihypertensive drugs used may cause potentially negative effects, e.g. by increasing serum lipoproteins. Finally, the pathophysiology behind stroke and myocardial infarcts differ in several respects, and this may contribute to the less favourable effects of antihypertensive treatment on coronary artery disease-morbidity as compared to stroke-morbidity.