Modern strategies in hypertension management

Despite the existence of various international and national hypertension management guidelines which emphasise the importance of blood-pressure control in minimising the risk of cardiovascular events, under-treatment of hypertension remains a significant clinical problem. There are many potential reasons for this, but it may be related, at least in part, to misperceptions concerning the efficacy and tolerability of antihypertensive therapy. The choice of antihypertensive therapy will depend on a variety of factors, including tolerability, efficacy, and the potential for protective effects on target tissues. The AT1-receptor blockers have been shown to have placebolike tolerability, and a recent study with candesartan confirms that these agents lack the potentially adverse metabolic effects seen with diuretics. There are significant differences in antihypertensive efficacy between AT1-receptor blockers: a metaanalysis using a standard pharmacological Emax model has shown that candesartan produces the greatest maximal antihypertensive effect, and losartan the smallest. Furthermore, the duration of action of AT1-receptor blockers varies. In comparative studies, candesartan has been shown to reduce blood pressure for up to 48 hours after dosing, whereas with some other agents the effect is markedly diminished at 24 hours after dosing. Recent data suggest that AT1-receptor blockers offer benefits beyond lowering of blood pressure, particularly in reducing the risk of stroke.