Whom to treat: The dilemma of mild hypertension

Abstract

In the past year, the results of three large clinical trials on the therapy of mild hypertension have been published-one from the U.S., one from Australia, the third from Oslo, Norway.l-a Based mainly oln the data of the U.S. trial, the Hypertension Detection and Follow-up Program (HDFP), the recent report of the Joint National Committee? states that “It is reasonable to reduce blood pressure even in uncomplicated mild hy:pertension by pharmacologic or nonpharmacologic therapy,” and that “the initial goal of antihypertensive therapy is to achieve and maintain diastolic pressure levels at less than 90 mm Hg.“4 However, a careful scrutiny of the results of all three trials leads me to a different, more conservative conclusion-namely, that drug therapy for uncomplicated hypertension is indicated only for those whose diastolic blood pressures remain at or above 100 mm H’g after 6 months of non-drug therapy. The difference in these views may look small, but in fact the management of about 20 million Americans is in question. The initial diastolic blood pressure (DBP) readings on the 158,906 persons aged 30 to 69 screened by the HDFP found 16.9% to be between 90 and 100 mm Hg. The 20 million figure derives from interpolating this percentage to the entire American population-a valid maneuver since the HDFP population was a previously unselected, representative sample chosen from 14 communities across the U.S. Basis for the more liberal view. In the HDFP, all patients with hypertension were included regardless of how high the blood pressure and how much cardiovascular disease already was present. Therefore, it was considered unethical to put half of the patients on a placebo. Rather, half were treated more intensively in special centers with intensive