Implications of recent hypertension trials for the generalist physician: whom do we treat, and how?

Lee Green

doi:10.1186/cvm-1-1-022

Abstract

The publication of the results of the Swedish Trial in Old Patients with Hypertension-2 (STOP-2) and the termination of the doxazocin arm of the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack (ALLHAT) study again raise the question of whether all antihypertensives deliver equal cardiovascular outcome benefits. Data from research on congestive heart failure and from the Heart Outcomes Prevention Evaluation (HOPE) trial illuminate the roles and possible mechanisms of humoral mediators of vascular damage, suggesting, first, that some antihypertensives (thiazides, beta-blockers, and angiotensin-converting enzyme inhibitors) can deliver more improvement in outcomes than other agents and, second, that decisions on whom to treat are best made based on risk appraisal, not merely pressures.

Highlights

The publication of the results of the Swedish Trial in Old Patients with Hypertension-2 (STOP-2) and the termination of the doxazocin arm of the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack (ALLHAT) study again raise the question of whether all antihypertensives deliver equal cardiovascular outcome benefits
The conflict centers around two key issues: does it matter how blood pressure is lowered?; and are there subsets of patients who benefit from antihypertensive drugs at lower pressures than we have conventionally believed, or who do not benefit unless pressures are higher than we have believed?
Not long after the publication of STOP-2, the doxazocin arm of the ALLHAT trial was terminated because of an excessive rate of development of congestive heart failure compared with thiazides [5], suggesting that how blood pressure is lowered may matter in terms of outcomes achieved

Summary

Joint National Committee

The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 2. Ramsay L, Williams B, Johnston G, MacGregor G, Poston L, Potter J, Poulter N, Russell G: Guidelines for management of hypertension: report of the third working party of the British Hypertension Society, 1999. 3. Wright JM, Lee CH, Chambers GK: Systematic review of antihypertensive therapies: does the evidence assist in choosing a first-line drug? 4. Hansson L, Lindholm LH, Ekbom T, Dahlof B, Lanke J, Schersten B, Wester PO, Hedner T, de Faire U: Randomised trial of old and new antihypertensive drugs on cardiovascular mortality and morbidity in elderly patients with hypertension: the Swedish Trial in Old Patients with Hypertension-2.

Messerli FH

10. Heart Outcomes Prevention Evaluation Study Investigators