Initial therapy in hypertension: quality-of-life considerations

Treatment has one of two fundamental goals, relief of symptoms or a change in natural history. In general, a treatment goal of symptom relief is easier to achieve. One treats each day for symptoms that day, and a patient's compliance is maintained when symptoms are relieved. Treatment that has as its goal a change in natural history, without providing symptom relief, is fundamentally more difficult: one treats today for events that might occur tomorrow--or months or years later. The revolution in what we have available for treatment has been accompanied by an evolution in expectations. In the area of hypertension the expectations are stringent. The physician cannot provide the patient with symptom relief, because there are no symptoms directly attributable to the hypertension--although few individuals are free of symptoms. The short-term goal is to control the high blood pressure at a minimal cost in adverse reactions; the long-term goal is to change natural history. Two decades ago antihypertensive therapy was restricted to very severe hypertension. The available agents were difficult to use, and they produced substantial side effects. Over the past several decades each wave of new agents has provided some improvement in efficacy, but primarily a reduction in the frequency and severity of adverse reactions. Today, at a time when we often wish to treat mild hypertension, the goal is to have patients feel as well on treatment as they do off it. A progressive reduction in the frequency and severity of central nervous system side effects is one of the major features of the evolution of therapy.(ABSTRACT TRUNCATED AT 250 WORDS)