Management of the patient with primary (essential) hypertension

Abstract

The blood pressure of many patients with primary hypertension may be lowered by low-sodium diets, antihypertensive drugs, or sympathectomy. Some of these patients treated with such measures are benefited. The physician must base and evaluate his treatment on an understanding of the natural history of primary hypertension in untreated patients. The possible benefits of treatment must be weighed against the disadvantages and dangers peculiar to each regimen in the various stages of the disease. The choice of treatment represents an experiment in each patient. Neither the antihypertensive effect nor the disadvantageous effects of any treatment can be predicted with confidence before trial in the individual. The choice of which agent to try first is made principally on an evaluation of the rapidity of progression of the disease process and on the patient's ability and willingness to follow the necessary regimen. Emphasis is placed on avoiding, when possible, the more complex and hazardous forms of therapy until the simpler and less hazardous ones have been found inadequate. Current experience permits certain generalizations: 1. 1. No specific treatment other than education is recommended for the patient in the asymptomatic uncomplicated phase. Symptoms, in the absence of demonstrable organ involvement, are treated conservatively. The alkaloids of Rauwolfia are sometimes useful. 2. 2. Progression of essential hypertension into the complicated phase implies the existence of atherosclerosis. All induced reductions in blood pressure in such patients carry the risk of significant local alterations in arterial blood supply. Changes are therefore made as slowly as possible. 3. 3. In the complicated phase of essential hypertension, even asymptomatic cardiac enlargement or any degree of decompensation justifies an attempt to lower the blood pressure. The possible hazards of the various forms of treatment and of lowered pressure are a limiting factor. 4. 4. Renal damage, without uremia, is considered an indication for antihypertensive therapy; the potential benefit far outweighs the disadvantages of treatment. The rate of progression of the disease determines the choice of therapeutic agents and the rapidity of pressure change desired. 5. 5. Acute hypertensive encephalopathic crises call for immediate lowering of the blood pressure by parenterally administered methonium compounds, if the facilities for their controlled administration are available. 6. 6. The value of prolonged antihypertensive therapy for most patients with cerebral damage has not been demonstrated. It is now sometimes possible to help patients with hypertension. It is more possible than ever before to hurt them.