Recent issues in antihypertensive drug therapy

Results of recent large scale treatment trials have demonstrated that aggressive management of high blood pressure prevents progression of mild hypertension to the accelerated or malignant phase and reduces incidence of stroke, congestive heart failure, and left ventricular hypertrophy. These trials mostly have utilized a diuretic-based, stepped-care approach to drug therapy, however, and have not shown a consistent beneficial effect of treatment on coronary heart mortality. In addition, the results of studies such as MRFIT have raised questions about serious risks of diuretic treatment in selected patients. These concerns have led to increased use of nonpharmacologic approaches to lowering blood pressure in patients with mild hypertension, but most patients ultimately require drug therapy. Alternative agents to diuretics now being employed as monotherapy in mild hypertension include beta-blockers, calcium channel blockers, ACE inhibitors, alpha-blockers, alpha- and beta-blockers, and, to a lesser extent, centrally-acting sympatholytics and peripheral adrenergic antagonists. Rational use of these agents primarily is based on a careful evaluation of concomitant medical conditions (see Table 3), as well as their mode of action, relative side effects, ease of administration, and cost. Age and race recently have been found to be important determinants of antihypertensive response to agents such as diuretics, beta-blockers, calcium channel blockers, and ACE inhibitors (see Table 3) and appreciation of these relative differences may affect drug selection. When these factors are taken into account, an effective and well tolerated regimen can be tailored to the individual patient. It is hoped that aggressive treatment of hypertension in the future will cause a further decline in cardiovascular mortality in the United States.