Antihypertensive Therapy

Mild-to-moderate essential hypertension is the most common medical problem seen by physicians in Western populations, and pharmacologic antihypertensive therapy is now usually undertaken. Clinical trials have shown that lowering of elevated blood pressure using diuretics and β-blockers reduces cardiovascular morbidity and mortality. Despite these benefits, the trials have provided no convincing evidence that the incidence of coronary artery disease or its complications is reduced: Treated hypertensive patients remain at increased cardiovascular risk compared with untreated normotensive subjects. Possible explanations for this disappointing outcome are that the drugs used may themselves have negative effects on serum lipids, glucose, and insulin resistance, thereby outweighing their antihypertensive benefits. An equally important role in this respect may be played by the diseases and therapies most commonly found in association with mild-to-moderate hypertension: hyperlipidemia, type II diabetes, coronary artery disease, left ventricular hypertrophy, cardiac arrhythmias, peripheral arterial disease, and nephropathy. Such conditions may be potent determinants of what constitutes the optimal first-line choice of antihypertensive therapy. Furthermore, the negative effects that antihypertensive drugs can have on quality-of-life factors may result in noncompliance and ineffective long-term treatment. Therefore, in a new therapeutic approach to the treatment of high blood pressure, it would be logical to base antihypertensive therapy on strategies that not only lower the blood pressure but that have beneficial impacts on hemodynamics, vascular and cardiac structure, metabolism, and quality-of-life issues. The favorable effects of newer classes of drugs, including angiotensin-converting enzyme (ACE) inhibitors, calcium antagonists, and postsynaptic a-blockers, on hemodynamics, cardiac structure, and metabolic and biochemical parameters as well as quality-of-life factors and side effect profiles are reasons for optimism that carefully tailored therapy using these agents ultimately will diminish the high risk of cardiovascular morbidity and mortality associated with hypertension. Although it has to be determined whether the newer classes of drugs are superior to diuretics and β-blockers in their ability to prevent coronary events, they appear to have greater potential for cardioprotection and maintenance of quality of life than other types of medications.