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Historical perspective on the management of hypertension
Insights
Significant advancements in hypertension management over 30 years have improved patient outcomes. Increased awareness and effective blood pressure control have led to reduced stroke and heart failure mortality rates.
Area of Science:
- Cardiovascular Medicine
- Pharmacology
Background:
- Hypertension affects approximately 25% of US adults.
- Historically, awareness and control of hypertension were very low.
Observation:
- In the 1960s, over 50% of hypertensive individuals were unaware of their condition, with less than 20% achieving controlled blood pressure.
- By the 1980s, awareness increased significantly, and over 60% of patients were treated to goal blood pressure levels.
Findings:
- Effective hypertension management is linked to a 45% decrease in stroke mortality and reduced incidence of renal and congestive heart failure.
- A portion of the 25-30% decrease in coronary mortality is also attributed to better hypertension management.
- The development of antihypertensive drugs, from 1950s agents to modern classes like ACE inhibitors and calcium channel blockers, has dramatically improved patient prognosis.
Implications:
- Continued research focuses on developing well-tolerated antihypertensive drugs with fewer metabolic side effects.
- Improved pharmacologic management of hypertension is crucial for reducing cardiovascular morbidity and mortality.
- This review critically examines clinical trials and challenges in antihypertensive drug therapy.
Abstract:
Remarkable progress has been made during the past 30 years in the management of hypertension, a disease that affects approximately one out of every four adults in the United States. In the 1960s, at least half of the individuals with hypertension were unaware of their disease, and the blood pressures of fewer than 20 percent were controlled at normotensive levels. In contrast, in the 1980s, only a small percentage, perhaps as few as 10 or 15 percent of hypertensive patients, are unaware of their disease and, in many parts of the country, more than 60 percent are being treated to goal blood pressure levels. More effective treatment of hypertension is probably a major reason for the 45 percent decrease in stroke mortality rates in the last 12 years alone and for the dramatic decrease in the number of hypertensive patients in whom renal failure or congestive heart failure develops. In addition, at least a portion of the 25 to 30 percent decrease in coronary mortality rates can probably be attributed to better management of patients with hypertension. The availability of antihypertensive drugs in the 1950s (rauwolfia preparations, veratrum derivatives, thiocyanates, hydralazine, and the ganglion blockers) and the discovery of more effective agents in the period from the 1960s to the present have dramatically improved the prognosis of hypertensive patients. Thiazide diuretics, centrally acting sympatholytic agents, beta-adrenergic inhibitors, and, more recently, selective alpha-adrenergic inhibitors, converting-enzyme inhibitors, and calcium entry blockers are examples of these medications. All of these agents have some side effects, with varying patient acceptability. The search continues for newer drugs that are well tolerated, that lower blood pressure by reducing peripheral resistance, and that produce few metabolic changes. A detailed review of the physiologic effects of antihypertensive medications, as well as a critique of the clinical trials and some of the problems noted in the pharmacologic management of hypertension, is presented.