Goals of Antihypertensive Treatment and Planning of Therapeutic Trials

The prevention of both cardiovascular events and organ damage or disease have to be considered to be different, but essential, goals of antihypertensive therapy. As the mechanisms that lead to organ damage and to events are, to a significant extent, different, it must be recognized that the achievement of the two goals has to be evaluated through trials using, separately or conjointly, different criteria. Thus far, randomized trials of antihypertensive therapy have almost exclusively measured mortality and morbidity data, and have provided information relevant to the prevention of cardiovascular events in those hypertensive patients in whom a relatively high rate of events is expected during the relatively short time span (3 to 6 years) of the trial, namely, those who have severe hypertension or who are elderly. However, in young or middle-aged patients with mild-to-moderate hypertension, for whom the goal of therapy would be to prevent or retard the development of vascular lesions to help these patients achieve their full life span, trials should be based on the measurement of organ damage rather than, or in addition to, the monitoring of events. The MIDAS trial has been the first in which two different modes of antihypertensive therapy have been tested for their capacity to influence the development of atherosclerosis in hypertension. It is likely that the results of this study will prompt many more therapeutic trials based on the quantitative assessment of organ damage in hypertension.