Calcium antagonists as first-choice therapy for low-renin essential hypertension

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A 55-year-old architect was referred to the Basel University Hypertension Clinic for evaluation of a 17-year history of high blood pressure in the range of 170—190/100—120 mm Hg. Antihypertensive treatment— including thiazide diuretics, beta blockers, alpha-methyldopa, and (early in the course) guanethidine and reserpine given alone or in combination—caused unwanted effects such as daytime fatigue, dry mouth, and impotence. The side effects interfered considerably with his quality of life. The family history was positive for hypertension. The patient had had 3 episodes of urinary tract infection but had no demonstrable abnormality by rapid-sequence intravenous pyelogram. He suffered often from pounding headaches, particularly during stress, but no palpitations, sweating, ororthostatic falls in blood pressure were observed. He had no additional cardiovascular risk factors: He had stopped smoking 7 years earlier, glucose tolerance was normal, and plasma cholesterol concentrations were below 6.5 mmol/liter. Body weight was 68 kg; height was 172 cm. Eight weeks following discontinuation of all antihypertensive medications, the blood pressure was 180/110 mm Hg with the patient seated. Physical examination showed evidence of an enlarged left ventricle, a grade li/Ill systolic ejection murmur, and a third heart sound. An electrocardiogram revealed left ventricular hypertrophy, and a plain chest film disclosed a cardiothoracic ratio of 0.6, the cardiac diameter being 15.5 cm. Laboratory evaluation revealed a serum potassium of 3.3