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Minerva Medica 2003 August;94(4):215-28

Copyright © 2003 EDIZIONI MINERVA MEDICA

language: English

Initial therapy for uncomplicated hypertension: insights from the alphabetic maze of recent studies

Stewart J. R., Yeun J. Y.

Some hypertension treatment guidelines published in the late 1990's recommended that diuretics and b-blockers be used as 1st line drugs for treating uncomplicated hypertension, reserving new antihypertensive drugs for special indications. This recommendation is predicated on the fact that large trials showing cardiovascular protection with antihypertensive drugs used b-blockers and diuretics. Other guidelines suggested all antihypertensives are equal and that drug selection should be individualized. These disparate guidelines arise from the controversy over ''are all antihypertensives created equal?'' Since these guidelines, many large hypertension trials have been conducted. This paper will review the recent hypertension trials, the meta-analyses of some of these trials, highlight some of the flaws inherent in the trials that making interpretation difficult, and finally outline a rationale approach to initial treatment of the uncomplicated hypertensive patient. It will provide a rationale for 1) using diuretic and not b-blocker as the 1st line agent in treating uncomplicated hypertension, 2) switching to an angiotensin converting enzyme inhibitor or angiotensin receptor blocker should side effects occur on diuretic, 3) reserving calcium channel blocker, b-blocker, and a-blocker for 2nd or 3rd line therapy, 4) employing a diuretic in combination with any other antihypertensive class, and 5) considering use of lower doses of 2 or more antihypertensives to limit side effects while optimizing blood pressure control. If the incidence of de novo diabetes is indeed higher with diuretics and cost-analysis confirm long-term savings with using a more expensive but less diabetogenic drug to treat hypertension, then the recommendation may shift to using an antihypertensive that acts on the renin-angiotensin axis.