INDIVIDUALIZATION OF THERAPY FOR HYPERTENSION IN THE 1990S - THE ROLEOF CALCIUM-ANTAGONISTS

The Joint National Committee Reports IV (1988) and V (1992) have empha sized individualization of drug therapy for patients with hypertension - a departure from the ''stepped'' care approach of initiating therap y with diuretics as advocated by the JNC I-III in the 1970's and 1980' s. This review highlights individualization or ''patient profiling'' u sing calcium channel blockers as first-line treatment strategy for pat ients with primary hypertension - especially in the patient who has at tendant risk factors and sequelae. The calcium channel antagonists, es pecially effective in elderly and Black patients, have;proven efficacy in reducing left ventricular hypertrophy and improving diastolic func tion in patients with hypertensive heart disease. The heart rate limit ing calcium antagonist, verapamil, has been found effective in outcome trials of reducing death and reinfarction rates post myocardial infar ction and is an alternative therapy for the beta blocker intolerant hy pertensive post myocardial infarction. More vascular specific dihydrop yridines (felodipine, isradipine, and amlodipine) may be preferable to rate limiting agents in hypertensives with sinus node or AV conductio n disorders and in those with impaired left ventricular systolic funct ion. Verapamil and diltiazem have been effective in preliminary trials in reducing proteinuria and preserving renal function in both diabeti c and non diabetic hypertensives. Calcium channel antagonists appear t o prevent the progress of atherosclerosis independent of their antihyp ertensive properties. Further, they have theoretic value in improving endothelial mediated vasodilation.