What we really need to do to reduce cardiovascular events in hypertensive patients

These achieved blood pressure differences although small, were significant. Small overall mean blood pressure differences could mask much larger blood pressure differences in the individual patient. Consider, for instance, the HOPE (Heart Outcomes Prevention Evaluation) trial, where a reported overall blood pressure difference of only 3/1 mm Hg between the 2 treatment arms masked a difference of 10/4 mm Hg in 24-hour ambulatory blood pressure and a difference of 17/8 mm Hg in night-time blood pressure.^39,40

Thus, instead of trying to work out why antihypertensive drugs could exert apparently different cardiovascular protective efficacy in different trials, the simple and consistent message is that the lower the achieved blood pressure, the lower the adverse clinical cardiovascular outcome.

What makes sense for your patient?

In selecting antihypertensive drugs, physicians should be guided by data supporting a particular drug in coexisting clinical conditions. (See “Where to begin when there are coexisting conditions,”.) In the hypertensive patient who is free of clinical disease, a case can be made for a diuretic as the first-line drug, although calcium channel blockers, ARBs, and ACE inhibitors can also claim evidence to support their use. In the older patient, beta-blockers—especially atenolol—should not be the drug of first choice.^35,36,41

As this review of comparative hypertension drug trials shows, multiple drugs are required for adequate blood pressure control in most patients. Thus, physicians should not be too preoccupied about how to initiate treatment, but remember to add drugs until adequate control is achieved.

Correspondence
H T Ong, FRCP, FACC, FESC, H T Ong Heart Clinic, 251C Burma Road, Penang 10350, Malaysia; htyl@pd.jaring.my