Antihypertensive Therapy: Patient Selection and Special Problems

Abstract

Antihypertensive therapy clearly is effective in reducing the overall incidence of morbidity and mortality from cerebrovascular and cardiovascular disease. Hypertension, whether systolic, diastolic, or isolated systolic, is a major risk factor for vascular and target organ damage. Systolic blood pressure, increased pulse pressure, and high baseline heart rate are definite cardiovascular risk factors. Recent data support the concept that even very mildly elevated blood pressure is associated with a substantial risk. Nonpharmacologic therapy alone may not be as effective as drug therapy superimposed on nonpharmacologic therapy in reducing that risk. Nevertheless, the milder the average blood pressure of the treatment group, the greater the number of people who must be treated in order to prevent a single stroke or myocardial infarction. In an increasingly cost-conscious society, the emphasis is on targeting effective single-drug, low-cost therapy to patients who are at the highest risk. We have progressed only a little in this regard. We do not yet have sophisticated markers of enzyme and receptor genotypes, which may someday increase our specificity of who we treat and how we treat them. Nevertheless, we can no longer justify decerebrate “shotgun” antihypertensive therapy. Conversely, we are a long way from achieving 100% therapeutic precision. Well-informed, thoughtful caregivers now have the data to approach that ideal goal.