Blood Pressure Reduction and the Risk of Myocardial Infarction

To the Editor.— Alderman and coworkers 1 document a dramatically lower rate of morbid and fatal events among ambulatory hypertensives who moderately reduce their diastolic blood pressure compared with those with small or large reductions. Their conclusions from this prospective study among a relatively high-risk population are robust over a range of stratifications by sociodemographic and risk factor categories. The authors suggest no clear pattern related to specific antihypertensive regimens, but the vast majority of subjects received hydrochlorothiazide or propranolol, alone or in combination. Citing many of the same confirmatory studies, Berglund 2 has summarized eight reports from 1978 through 1987 consistent with the conclusion that moderate diastolic blood pressure reduction is superior to either extreme. None of these reports, however, acknowledges the potential confounding influence of medication compliance, presumably because of the many difficulties in measuring it accurately, unobtrusively, and prospectively. 3 Partial compliance with prescribed medication, especially