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Commentary |

Is It Time for a New Approach to the Initial Treatment of Hypertension?

Marvin Moser, MD
Arch Intern Med. 2001;161(9):1140-1144. doi:10.1001/archinte.161.9.1140.
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RESULTS OF recent trials in the management of hypertension indicate that an update of recommendations for initial therapy may be indicated.19

In 1997, the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI)10 recommended that diuretics or β-blockers be chosen as initial therapy if lifestyle modifications failed to reduce blood pressure to goal levels, unless there were specific or compelling reasons to use other drugs. At that time, the decision was based on the fact that, other than 1 or 2 studies, all of the placebo-controlled morbidity and mortality outcome clinical trials had used diuretics or β-blockers as initial treatment. Results had been impressive, with a decrease of 38% in strokes, 16% in coronary heart disease events, and more than 40% in the occurrence of heart failure.11,12 One trial, the Systolic Hypertension Europe (Syst-Eur) trial, had used nitrendipine, a moderately long-acting calcium channel blocker (CCB), as initial therapy, with other medications added if necessary.13 This trial reported a significant decrease in strokes and overall cardiovascular events, but not in coronary heart disease events, probably because the study was stopped after only 2 to 2½ years. On the basis of this study, the JNC-VI had suggested that use of a long-acting CCB might be appropriate therapy in patients with isolated systolic hypertension if a diuretic was poorly tolerated or ineffective. These recommendations, based on available outcome evidence, seemed reasonable at the time.

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Initial pharmacological treatment of hypertension. These data have been modified and updated from the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Asterisk indicates that other fixed-dose combinations of 2 different classes of drugs may also be appropriate initial therapy in some cases (diuretic/angiotensin II receptor blockers [ARBs] or angiotensin-converting enzyme inhibitor [ACEI]/calcium channel blocker).

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