Profile of hypertensives as a determinant of long-term antihypertensive medication needs

The experience of 110 hypertensives who participated in a worksite stepped-care treatment program has been examined to draw a patient profile at entry that would determine medication needs on a long-term basis. Patients entered untreated with a blood pressure (BP) level of greater than or equal to 160 mm Hg systolic and/or greater than or equal to 95 mm HG diastolic (DBP) and had a minimum follow-up of 1 year. Treatment was initiated with diuretics, and additional drugs were added as necessary to achieve BP control. Patients were divided into three groups according to initial DBP levels: Group A (33 patients, greater than or equal to 105 mm Hg), Group B (43 patients, 95-104 mm Hg), and Group C (34 patients, less than 95 mm Hg). Using a life table method, we analyzed the therapeutic experience of these patients to obtain 5-year cumulative rates of adding a second drug to diuretics. Within the first 2 years of treatment, the cumulative rates were: 64% in Group A, 33% in Group B, and 23% in Group C. In all three groups the rates after the second year remained stable. This stepped-care approach resulted in BP control (less than 160/95) which ranged from 78% in the first year to 96% in the fifth year. Findings suggest that initial DBP level and age are principal factors in determining medication needs. Furthermore, at higher DBP levels, younger nonwhite and younger white males are most likely to require a second drug within the first year of treatment. The need for a second drug is apparent within the first 2 years.

The potential effect of blood pressure reduction on cardiovascular disease. A cautionary note

The risk of cardiovascular disease (CVD) at various levels of systolic blood pressure (BP) and the potential benefit of BP reduction have been estimated by constructing probability tables for extended periods based on the Framingham Study data. These estimates demonstrate that systolic BP alone delineates subgroups of persons with widely divergent risk of CVD, depending both on their demographic and clinical characteristic. For example, the disparity in prognosis is such that some persons with a systolic BP of 160 mm Hg are at greater risk of subsequent CVD than others with a systolic BP of 195 mm Hg. The potential benefit to be derived from systolic BP reduction shows similarly wide variation, so initial pressure alone does not precisely predict the gain that might accompany BP reduction. Measures of greater prognostic value are needed to enhance the value of BP determination.

Management of the hypertensive patient: a continuing dilemma

The proper management of mild and moderate hypertension remains a matter of considerable professional disagreement. Major clinical and population research has largely been designed to define a level of blood pressure (BP) at which treatment should be initiated. This paper reviews studies of the natural history of hypertension and the findings of intervention trials to determine whether the BP level alone is adequate to identify, diagnose, and predict the future course of hypertensive patients. Observational data suggest that patients defined by mild elevation of BP are a heterogeneous group who do not share a common prognosis. Moreover, intervention trials reveal that not all those at risk of cardiovascular disease will benefit from hypotensive therapy. Thus, BP level alone defines neither the group at risk nor those likely to benefit from BP reduction. It is therefore concluded that the management of each patient with hypertension should be determined on the basis of available clinical, biochemical, and behavioral as well as epidemiological data.