Management of the hypertensive patient: a continuing dilemma

The proper management of mild and moderate hypertension remains a matter of considerable professional disagreement. Major clinical and population research has largely been designed to define a level of blood pressure (BP) at which treatment should be initiated. This paper reviews studies of the natural history of hypertension and the findings of intervention trials to determine whether the BP level alone is adequate to identify, diagnose, and predict the future course of hypertensive patients. Observational data suggest that patients defined by mild elevation of BP are a heterogeneous group who do not share a common prognosis. Moreover, intervention trials reveal that not all those at risk of cardiovascular disease will benefit from hypotensive therapy. Thus, BP level alone defines neither the group at risk nor those likely to benefit from BP reduction. It is therefore concluded that the management of each patient with hypertension should be determined on the basis of available clinical, biochemical, and behavioral as well as epidemiological data.