Update on the management of hypertension: do recent clinical trial results indicate a change in national recommendations for therapy?
Numerous hypertension treatment trials have been reported during the past several years. In comparative studies it has been shown that the use of diuretics or diuretics/beta blockers has resulted in a reduction in morbidity/mortality equivalent to the use of other antihypertensive medications. This is true in both young and elderly patients. In one large 8-year study in diabetics, the use of a beta blocker/diuretic combination was shown to be as effective in reducing overall cardiovascular events as an angiotensin-converting enzyme (ACE) inhibitor/diuretic treatment program. Although most data indicate that the degree of blood pressure lowering accounts for most of the benefit, there are some differences in outcome that may be explained by different mechanisms of drug action. For example: 1) diuretics are more effective in preventing heart failure and overall cardiovascular events than alpha blockers; 2) an ACE inhibitor-based program is more effective in the elderly in reducing myocardial infarctions and heart failure than a calcium channel blocker-based program; and 3) a nondihydropyridine is more effective in reducing strokes, but less effective in preventing myocardial infarctions or heart failure, than a program based on diuretic therapy. There is also abundant evidence that the use of ACE inhibitors may prevent the occurrence of diabetes in hypertensive individuals and will reduce cardiovascular events in diabetics. Finally, the angiotensin receptor blockers have been shown to slow the progression of renal disease and prevent the occurrence of end-stage renal disease when compared to treatment regimens that do not include an angiotensin receptor blocker or ACE inhibitor. Updated treatment recommendations should include an ACE inhibitor and possibly an angiotensin receptor blocker along with diuretics and beta blockers as initial therapy. In addition, recommendations for the use of multiple-drug therapy have been reinforced by recent trials. Goal pressures are not readily achieved with monotherapy, especially in high-risk patients.