Selection Of Antihypertensive Therapy Research Articles

Chronotherapy of hypertension: current state of the problem and prospects

Chronotherapy for hypertension has been a topic of debate over the past decade. A number of studies up to 2019 suggested that prescribing drugs in the evening has advantages compared to morning, both in terms of normalization of blood pressure and its circadian rhythm, as well as in terms of the risk of adverse outcomes. Some of these studies were not designed for such an analysis, and some have significant limitations that make their interpretation difficult. The results of the HARMONY and TIME studies published in the last 2 years did not confirm any advantage of taking drugs in the evening compared to the morning, but showed its safety. Selection of antihypertensive therapy should be guided by antihypertensive efficacy, duration and stability of the effect, as well as medical adherence. Therefore, a single intake of double or triple fixed-dose combination of long-acting agents at hours convenient for the patient is optimal.

Diagnostics and treatment of resistant arterial hypertension

Resistant arterial hypertension is diagnosed when three antihypertensives assignment does not result in achieving target blood pressure, which for most patients is the level below 140/90 mm Hg, wherein one of the medicaments must be diuretic and all drugs must be assigned to optimal or maximum tolerated doses. Despite the high prevalence of resistant arterial hypertension, the lack of blood pressure control is often associated with an inadequate selection of antihypertensive therapy, blood pressure misjudgement or failure of patients to medical recommendations. Therefore, before carrying out diagnostic measures necessary to consistently assess the adequacy of patients receiving therapy that inherent in the definition of RAH and exclude pseudoresistance.

Effectiveness of personalized selection of antihypertensive therapy based on genetic polymorphism

Abstract Recent data indicate that it is important to develop the problem of genetic polymorphism in patients with arterial hypertension (AH) for the long-term possibility of using it as a justification for choosing the optimal treatment strategy. Currently, despite the availability of effective antihypertensive agents, the percentage of patients who have reached the target blood pressure level remains still not enough. A rational basis for choosing a particular class of drugs and / or their combinations in a concrete patient with AH can be the detection of genetic markers that determine the degree of sensitivity to therapy, since the relationship of its effectiveness with the genetic features is not in doubt today. Material and methods The work is based on the results of a clinical, instrumental, laboratory and genetic examination of 41 patients with AH with insufficient effectiveness of previous antihypertensive therapy. The median age and duration of the disease were 54 (32; 70) years and 7 (1; 20) years, respectively. Taking into account the identified gene polymorphism, a fixed combination of an ACE inhibitor (perindopril 10 mg) and a thiazide-like diuretic (indapamide 2.5 mg) was assigned. The comparative dynamics of blood pressure daily monitoring, left ventricle echocardiographic parameters, as well as indicators of vascular wall stiffness were analyzed before therapy and 3 months later. Results The study established a relationship between the clinical and morpho-functional features of AH in the examined patients with polymorphism of the AGT, AGTR2, CYP11B2, GNB3, NOS3 genes:-786 of their heterozygotes and “mutant” homozygotes, of which 3 polymorphic genes (AGT, AGTR2, CYP11B2) encode the activity of ACE. The obtained results allowed to establish that positive dynamics of the studied indicators was revealed in all patients. Though patients, carriers of the mutant allele C of polymorphic marker T704C AGT gene, had statistically significant more expressed benefit changes in blood pressure daily profile, echocardiographic parameters (such as left ventricular mass index, indicators of left ventricular diastolic function) and all parameters of arterial wall stiffness compared with patients who do not carry the “mutant” allele. Conclusion Thus, the selected treatment regimen demonstrated maximum antihypertensive, cardio - and vasoprotective effectiveness in the group of AH patients with the presence of the allele 704C of the polymorphic marker T704C of the AGT gene, which indicates the perspectivity of using genetic approaches to develop personalized tactics of AH patients drug treatment. Funding Acknowledgement Type of funding source: None

Problem of expertise of professional suitability of workers of metallurgical production

There are presented results of the expertise of professional suitability of workers of the steel industry with diseases of the cardiovascular system after selection of antihypertensive therapy.

Научное обоснование персонифицированного выбора антигипертензивной терапии и тактики ведения беременных с гипертензивными расстройствами

Научное обоснование персонифицированного выбора антигипертензивной терапии и тактики ведения беременных с гипертензивными расстройствами

Initial combination therapy for primary open-angle glaucoma

To study the efficacy and safety of initial combination therapy in patients with primary open-angle glaucoma (POAG). The study included 111 patients (161 eyes) with stages II-III b-c of POAG aged 46 to 89 years (mean age 70.8±8.5 years). In the test group, therapy began with a fixed combination of prostaglandin (PG) (latanoprost) and beta-blocker (BB) (timolol). In patients of the control group, POAG therapy began with administration of the analogue of prostaglandin (latanoprost). When the target IOP was not achieved, a second drug was added to the treatment - instillations of 0.5% solution of timolol maleate 2 times a day. In patients of the test group the treatment started with a combination of BB + PG, the target IOP in the 'worst' eyes was achieved in 33 cases (64%) in 1.5±0.6 visits, and in the 'best' eyes - in 17 cases (81%), in 1.2±0.4 visits. In the control group with a 'step-by-step' selection of antihypertensive therapy, the target IOP in the 'worst' eyes was achieved in 35 cases (59%), in 2.5±0.7 visits, and in the 'best' eyes - in 22 cases (76%), in 2.2±0.5 visits (p<0.05). In both study groups, there were no cases of drug withdrawal attributed to their side effects. Patients noted conjunctival hyperemia in 5% (4 eyes) and 7% (6 eyes) of cases in the test group and the control group, respectively (p>0.05). Hyperemia decreased significantly in 2 weeks of latanoprost administration or fixed combination and did not cause withdrawal. Initial combination therapy is possible in patients with newly diagnosed POAG in some clinical situations, namely in stages II-III POAG with high IOP, unavailability of regular observation of patients for various social and economic reasons, absence of somatic and local contraindications to individual components of the combined treatment, etc.

Сlinical and anamnestic features and their prognostic value in assessment of treatment effiiency of arterial hypertension with comorbidity

Antihypertensive treatment leads to regression of left ventricular hypertrophy, reduces the incidence of cardiovascular complications and improves survival rates, and this occurs regardless of the degree of lowering of blood pressure (BP). The aim of the study was to determinate the prognostic significance of clinical and anamnestic factors in the evaluation of effectiveness of therapeutic correction of arterial hypertension (AH) associated with obesity and diabetes mellitus by angiotensin II receptors blocker, telmisartan. Material and methods. 135 patients were examined, diagnosed with AH stage I–II associated with obesity of 1–2 degrees (mean age 61.6 ± 6.7 years). Duration of study was 3 month. Chronic heart failure was no worse than II functional class by NYHA. Evaluation of prognostic properties of the studied factors was carried out using sequential hypothesis by Wald–Genkin, according to which all the indices were ranged with the subsequent determination of the prognostic coefficient (PC) and the general informativeness of the index (I). The groups were matched by sex, age, severity of the clinical condition, concomitant pathology. The control group consisted of 20 practically healthy persons of similar age and sex without signs of disease. Results . In the study, the predictive value of clinical and anamnestic parameters of the effectiveness of antihypertensive treatment was analyzed. The results show that some clinical and anamnesis factors of the disease can be used to determine the telmisartan effectiveness in the treatment of hypertension with obesity. The most informative criteria (I > 1.0) are the duration (more than 11 years) of arterial hypertension, as well as the age of the patient and the presence of concomitant pathology, in particular type 2 diabetes and obesity. Conclusions . Based on the obtained data about the value of clinical and anamnestic factors’ significance in assessing of the antihypertensive therapy in patients with co-morbid pathology, it is assumed that patients with hypertension duration of more than 11 years with concomitant obesity and type 2 diabetes and those older than 71 years require special tactics in the selection of antihypertensive therapy. And, most likely, such patients need more frequent adjustment of the doses of the drug.

Organoprotection with arterial hypertension 2-3 degrees

Objective. Arterial hypertension (AH) is one of the most common and socially significant diseases worldwide. Despite years of experience gained in studying hypertension, the problems concerning selection of antihypertensive therapy with pleiotropic organ-protecting effects are still of current importance. Purpose - to assess therapeutic efficacy and pleiotropic organ-protective capability of third-generation calcium antagonist lercanidipine in patients with stage 2-3 hypertension. Materials and methods. Our study enrolled a total of ninety-two 31-to-84-year-old patients. Of these, 72 patients diagnosed as having stage 2 or 3 AH composed the Study Group and 20 apparently healthy subjects were included into the Control Group. At baseline and after 6 months, all patients of the Study Group underwent examinations consisting in measuring biochemical parameters [total cholesterol (TCH), triglycerides, low-density lipoprotein cholesterol (LDL CH), uric acid, urea, creatinine, glucose], 24-hour ambulatory BP monitoring, echocardiography in order to assess the dimensions and volume of the cardiac chambers, thickness of the left ventricular posterior wall (LVPW) and left-ventricular myocardium mass index (LVMMI), studying microalbuminuria (MAU), a known marker of endothelial dysfunction and early renal lesion; assessing the state of the vascular wall by the ankle-brachial index (ABI) and pulse pressure (PP). Antihypertensive therapy consisted in lercanidipine alone taken at a dose of 10-20 mg/day, failure to thereby achieve the target BP level was followed by additionally prescribing an angiotensin converting enzyme (ACE) inhibitor, enalapril, given at a dose of 5-20 mg twice daily. Results. All patients by the end of the study achieved the target level of AP (p≤0.05), also demonstrating significantly improved (p≤0.01) parameters of endothelial dysfunction and an early marker of renal damage (MAU), indices of elastic properties of the vascular wall ABI (p≤0.05) and PP (p=0.01). Significantly positive dynamics was observed for the following parameters: decreased creatinine concentration (p≤0.001), increased GFR (p≤0.001), decreased levels of TCH (p≤0.01) and LDL CH (p≤0.001). Conclusion. Lercanidipine therapy of patients with stage 2-3 AH proved highly efficient, well tolerated, metabolically neutral with pleiotropic organprotecting properties in the form of improved condition of the vascular wall, correction of endothelial dysfunction, nephroprotective action

Selection of antihypertensive therapy in elderly patients, combination therapy: thiazide-like diuretics and calcium channel blockers

The article presents data about the prevalence and expected prognosis for arterial hypertension. Emphasis is placed on the selection of antihypertensive therapy in elderly patients. The features concerning the positive effect of the calcium channelblocking agent — amlodipine, thiazid­like diuretic — indapamide retard in the form of monotherapy and a combination of the above drugs on the course and prognosis of arterial hypertension in elderly patients are investigated. A clinical example of the use of the fixed dose combination amlodipine + indapamide retard is also introduced.

Effective end-organ protection in arterial hypertension: possibilities of third-generation calcium antagonists

Objective:Arterial hypertension (AH) is one of the most common and socially significant diseases worldwide. Despite years of experience gained in studying hypertension, the problems concerning selection of antihypertensive therapy with pleiotropic organ-protecting effects are still of current importance. The purpose of the study was to assess therapeutic efficacy and pleiotropic organ-protective capability of third-generation calcium antagonist lercanidipine in patients with stage 2-3 hypertension.Method:Our study enrolled a total of ninety-two 31-to-84-year-old patients. Of these, 72 patients diagnosed as having stage 2 or 3 AH composed the Study Group and 20 apparently healthy subjects were included into the Control Group. At baseline and after 6 months, all patients of the Study Group underwent examinations consisting in measuring biochemical parameters [total cholesterol (TCH), triglycerides (TG), low-density lipoprotein cholesterol (LDL CH), uric acid, urea, creatinine, glucose], 24-hour ambulatory BP monitoring, echocardiography (EchoCG) in order to assess the dimensions and volume of the cardiac chambers, thickness of the left ventricular posterior wall (LVPW) and left-ventricular myocardium mass index (LVMMI), studying microalbuminuria (MAU) , a known marker of endothelial dysfunction and early renal lesion; assessing the state of the vascular wall by the ankle-brachial index (ABI) and pulse pressure (PP). Antihypertensive therapy consisted in lercanidipine alone taken at a dose of 10-20 mg/day, failure to thereby achieve the target BP level was followed by additionally prescribing an angiotensin converting enzyme (ACE) inhibitor, enalapril, given at a dose of 5-20 mg twice daily.Results:All patients by the end of the study achieved the target level of AP (p<0.05), also demonstrating significantly improved (p<0.01) parameters of endothelial dysfunction and an early marker of renal damage (MAU), indices of elastic properties of the vascular wall ABI (p<0.05) and PP (p=0.01). Significantly positive dynamics was observed for the following parameters: decreased creatinine concentration (p<0.001), increased GFR (p<0.001), decreased levels of TCH (p<0.01) and LDL CH (p<0.001).Conclusion:Lercanidipine therapy of patients with stage 2 - 3 AH proved highly efficient, well tolerated, metabolically neutral with pleiotropic organ-protecting properties in the form of improved condition of the vascular wall, correction of endothelial dysfunction, nephroprotective action.

Short-term esmolol attenuates remodeling of the thoracic aorta in hypertensive rats by decreasing concentrations of ADMA down-regulated by oxidative stress

Esmolol produces early regression of left ventricular hypertrophy and improves coronary artery remodeling, although the impact of short-term treatment with this beta-blocker on remodeling in large arteries has not yet been studied. We hypothesized that even a short (48h) course of esmolol might alter remodeling of the aorta in the spontaneously hypertensive rat (SHR). Fourteen-month-old male SHRs were treated intravenously with vehicle (SHR, n=8) or esmolol (SHR-E, n=8) (300μg/kg/min). Age-matched, vehicle-treated male Wistar-Kyoto rats (WKY, n=8) served as controls. After 48h, we studied the structure, volume density of elastic fibers, and passive mechanical properties of the aorta. Determination of asymmetrical dimethylarginine concentrations and total protein carbonyls in the aorta were analyzed. Esmolol significantly attenuated abnormal aortic wall thickness, cross-sectional area, wall-to-lumen ratio, volume density of elastic fibers, and wall stiffness. The protective effect of esmolol could be related to a decrease in asymmetrical dimethylarginine levels after down-regulation by oxidative stress. These findings could play a key role in the selection of antihypertensive therapy in patients with hypertension and aortic remodeling.

Выбор антигипертензивной терапии для пациентов пожилого возраста

Выбор антигипертензивной терапии для пациентов пожилого возраста

Associations between ADRB1 and CYP2D6 gene polymorphisms and the response to β-blocker therapy in hypertension.

To investigate the associations between β1-adrenergic receptor (ADRB1) and cytochrome P450 2D6 (CYP2D6) gene polymorphisms and β-blocker treatment outcomes in patients with hypertension. Chinese patients with essential hypertension were treated with the β-blocker metoprolol and followed up for 12 weeks. xTAG® liquid-chip technology was used for CYP2D6 100 C > T and ADRB1 1165G > C genotyping. Associations between gene polymorphisms and antihypertensive therapy outcomes were assessed by generalized linear model fitting. A decrease of ≥ 10 mmHg in systolic blood pressure indicated an effective treatment outcome. A total of 93 patients were included in the study. Mutant allele frequencies of 61.29% and 58.60% were obtained for ADRB1 and CYP2D6, respectively. There was no significant interaction between the effects of ADRB1 and CYP2D6 gene polymorphisms on treatment outcome. Patients homozygous for the mutant ADRB1 genotype (CC) had better treatment outcomes than those heterozygous for the mutation (GC). Interestingly, β-blocker treatment duration was an independent factor associated with treatment outcome. The ADRB1 1165G > C gene polymorphism and β-blocker treatment duration are independent factors associated with β-blocker treatment outcome. These findings suggest that the selection of antihypertensive therapy should take into consideration the patient's genotype.

IMPROVING THE METHODOLOGY OF CONTINUOUS MEDICAL EDUCATION IN THE CONTEXT OF ARTERIAL HYPERTENSION TREATMENT

Aim. To assess the role of the algorithm-based selection of antihypertensive therapy (AHT) and the continuous medical education in the treatment of arterial hypertension (AH).Material and methods. Based on the autopsy data, we analysed the prevalence of AH and the structure of its complications and comorbidities among 3239 patients of a multidisciplinary Moscow City hospital. We also analysed the practices of preceding ambulatory AHT and conducted the survey on the quality of continuous medical education lectures delivered to internal medicine specialists working at polyclinics.Results. Among patients who died from cardiovascular disease, a high prevalence of AH (96,1%) was combined with prevalent target organ damage (TOD), a strong association between blood pressure (BP) levels and the risk of major cardiovascular events, and a wide range of comorbidities and AH complications. There was a lack of universal AHT schemes and regimens for patients of similar age, gender, and nature and severity of comorbidities.Conclusion. Achievement of target BP levels failed to prevent major cardiovascular events which resulted in fatal outcomes. AHT was administered without adequate consideration of organo-protective and pleiotropic effects of antihypertensive medications. The development of an algorithm which considered age, gender, TOD presence, and previous major cardiovascular events in the selection of AHT had improved the doctors’ understanding of the lecture information.

Pharmacogenomics of antihypertensive drugs: Rationale and design of the Pharmacogenomic Evaluation of Antihypertensive Responses (PEAR) study

Selection of antihypertensive therapy is often empiric, and use of genetic information to guide drug therapy selection holds future promise. The objective of this trial is to identify the genetic determinants of the antihypertensive and adverse metabolic responses to a thiazide diuretic (hydrochlorothiazide), a beta-blocker (atenolol), and their combination. This will be accomplished through candidate gene and genome-wide association approaches. Individuals with uncomplicated hypertension (N = 800), with ages 17 and 65 years, are being enrolled. Current antihypertensive therapy is discontinued, and hypertension is confirmed, along with collection of other baseline data. Subjects are then randomized to either hydrochlorothiazide or atenolol, with 1 dose titration step, followed by assessment of response to therapy after at least 6 weeks on the target dose. Those with blood pressure >120/70 mm Hg have the second drug added, with similar dose titration and response assessment procedures. Data collected include home, office, and 24-hour ambulatory blood pressure. Biological samples collected in the fasting state include plasma, serum, DNA (buffy coat), and urine. Epstein-Barr virus transformed lymphocyte cell lines are also being created. Pharmacogenetic-guided therapy holds clinical potential for hypertension, but the literature in the field is limited. This trial will add substantially to our understanding of the genetic determinants of antihypertensive and adverse metabolic responses to 2 commonly used antihypertensive drug classes.

Noninvasive Hemodynamic Measurements

It has been well established that effective blood pressure (BP) lowering, using various antihypertensive agents with different mechanisms of action, lowers the risk for cardiovascular morbidity and mortality.1–4 However, when hypertensive populations are partitioned into subgroups by race, sex, geography, and age, differences in BP responses to single antihypertensive drugs emerge, albeit at the group level, that have been used to guide therapy for individuals within these contrasted groups.1,5,6 With respect to race, perhaps the most widely used group characteristic used to guide individual therapy, we5 and Sehgal6 have argued that the observed racial differences in BP response overlap to such a large degree that, by far, the greatest source of variation in BP response is within rather than between groups. This observation renders the use of group characteristics as grossly suboptimal criterion on which to base therapy for all individuals of a group. The inaccuracy of blanket extrapolation of group characteristics to predict BP responses for individuals is also likely to be true for traits such as geographic residence, age, and sex. Thus, the findings reported by Smith et al7 in this issue of Hypertension were very encouraging. These investigators showed that consideration of hemodynamic parameters, as determined noninvasively by impedance cardiography (IC) (BioZ, Cardiodynamics), in the selection of antihypertensive therapy in primary care practice settings improved rates of BP control and normalization of selected hemodynamic parameters in drug-treated hypertensives with BP >140/90 mm Hg. They …

The association of hypertension and diabetes: prevalence, cardiovascular risk and protection by blood pressure reduction

Diabetes and hypertension frequently coexist, and their combination provides additive increases in the risk of life-threatening cardiovascular events. Recent guidelines agree on the need for early, aggressive reduction of blood pressure, with a goal of <130/80 mmHg, in patients with diabetes. The mechanism that underpins the increased sensitivity of diabetic subjects to hypertension is not known, but may involve impaired autoregulation or attenuated nocturnal decrease of blood pressure. All classes of antihypertensive agents are effective in reducing blood pressure in diabetic subjects, and all show evidence of a concomitant reduction in cardiovascular risk. Although there is some evidence that agents that interrupt the renin-angiotensin system (RAS) provide greater protective effects, the data are not conclusive. However, most diabetic subjects will require combination therapy to reach goal blood pressure. Antihypertensive drugs can also significantly influence the probability that otherwise healthy individuals will develop metabolic syndrome or type 2 diabetes. While diuretics and betablockers have a prodiabetic effect, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers may prevent diabetes more effectively than the metabolically neutral calcium channel blockers. Given that diabetes is an important cardiovascular risk factor, there is the potential for reductions in risk due to reduced blood pressure to be offset by an increased risk due to the development of diabetes. Such concerns should be considered in the selection of antihypertensive therapy.

Renal Protection in Hypertensive Patients: Selection of Antihypertensive Therapy

Hypertension is common in chronic renal disease and is a risk factor for the faster progression of renal damage, and reduction of blood pressure (BP) is an efficient way of preventing or slowing the progression of this damage. International guidelines recommend lowering BP to 140/90 mm Hg or less in patients with uncomplicated hypertension, and to 130/80 mm Hg or less for patients with diabetic or chronic renal disease. The attainment of these goals needs to be aggressively pursued with multidrug antihypertensive regimens, if needed. The pathogenesis of hypertensive renal damage involves mediators from various extracellular systems, including the renin-angiotensin system (RAS). Proteinuria, which occurs as a consequence of elevated intraglomerular pressure, is also directly nephrotoxic. As well as protecting the kidneys by reducing BP, antihypertensive drugs can also have direct effects on intrarenal mechanisms of damage, such as increased glomerular pressure and proteinuria. Antihypertensive drugs that have direct effects on intrarenal mechanisms may, therefore, have nephroprotective effects additional to those resulting from reductions in arterial BP. Whereas BP-lowering effects are common to all antihypertensive drugs, intrarenal effects differ between classes and between individual drugs within certain classes. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) have beneficial effects on proteinuria and declining renal function that appear to be mediated by factors additional to their effects on BP. These RAS inhibitors are recommended as a first-line antihypertensive approach in patients with chronic kidney disease. The addition of diuretics and calcium channel antagonists to RAS inhibitor therapy is also considered to be a rational strategy to reduce BP and preserve renal function. Calcium channel antagonists are a highly heterogeneous class of compounds, and it appears that some agents are more suitable for use in patients with chronic renal disease than others. Manidipine is a third-generation dihydropyridine (DHP) calcium channel antagonist that blocks both L and T-type calcium channels. Unlike older-generation DHPs, which preferentially act on L-type channels, manidipine has been shown to have beneficial effects on intrarenal haemodynamics, proteinuria and other measures of renal functional decline in the first clinical trials involving hypertensive patients with chronic renal failure. Preliminary results from a trial in diabetic patients who had uncontrolled hypertension and microalbuminuria despite optimal therapy with an ACE inhibitor or an ARB suggest that manidipine may be an excellent antihypertensive drug in combination with RAS inhibitor treatment in order to normalise BP and albumin excretion in patients with diabetes.

Pheochromocytoma: an approach to antihypertensive management.

Pheochromocytoma and paragangliomas are rare tumors of chromaffin tissue that secrete catecholamines either intermittently or continuously, producing hypertension with a constellation of symptoms and signs that can be frightening to the patient and that continue to provide perplexing problems for clinicians. With surgical treatment, symptoms will be relieved and hypertension normalized or ameliorated for patients who do not have malignant tumors. Appropriate antihypertensive drugs are used to manage hypertension, to control associated cardiovascular symptoms, and to prepare patients for operation. The question debated most often regarding medical therapy of pheochromocytoma is whether antihypertensive treatment regimens other than nonspecific alpha-blockade are just as effective and safe. Understanding the pathophysiologic mechanisms that sustain the hypertension and the pharmacology of antihypertensive agents allows better selection of antihypertensive therapy.

Individualised selection of antihypertensive therapy.

Theoretically, it should be possible to match the requirements of individual patients with the pharmacological and clinical properties of the large number of antihypertensive drugs now available. The concept of automatic sequential stepped-care therapy is now largely outdated, but therapy of clinically important hypertension must be initiated with one agent. Diuretics remain a first-line option in the elderly and in Black patients, as do calcium antagonists. Outcome trials are available only for the elderly, and in these the benefits of initial diuretic therapy are well documented. Nonetheless, diuretics may often need to be co-prescribed with a beta-blocker or an adrenergic modifier such as methyldopa. beta-Blockers are preferred in patients with ischaemic heart disease or enhanced adrenergic drive, while alpha-blockers are preferred in patients with blood lipid abnormalities or prostatic problems. Calcium antagonists or angiotensin converting enzyme (ACE) inhibitors are being increasingly used as initial therapy when quality of life is important and metabolic neutrality is required. Calcium antagonists are more likely to be effective first-line therapy than ACE inhibitors in patients with a high salt intake, in patients with Raynaud's disease, when angina pectoris is present, and in Black patients. ACE inhibitors are preferred for combination with diuretic agents, and in the presence of congestive heart failure or low salt intake. Experimentally, both calcium antagonists and ACE inhibitors can prevent ischaemic ventricular fibrillation and atheroma. Combination therapy between these 2 drug classes is gaining increasing acceptance because of these theoretical advantages.(ABSTRACT TRUNCATED AT 250 WORDS)