CURRENT PHARMACOTHERAPEUTIC STRATEGIES IN THE TREATMENT OF ARTERIAL-HYPERTENSION

The aim of the treatment of hypertensive disease is to reduce its asso ciated cardiovascular morbidity and mortality. Simply reducing blood p ressure levels is clearly not adequate since its impact on coronary he art disease is particularly unsatisfactory. Moreover, the beneficial e ffects of antihypertensive treatment seem to plateau for several years , and the incidence of cardiac and renal failure is even increasing. T herefore, recommendations by groups of national or international exper ts are periodically updated on the basis of current epidemiological da ta. Two such recommendations appeared in 1997, one from the Agence Nat ionale d'Accreditation et d'Evaluation en Sante (ANAES) in France and the other from the Joint National Committee (JNC) on Prevention, Detec tion, Evaluation and Treatment of High Blood Pressure, in the United S tates. Both advocate the use of lifestyle modifications in all patient s. The threshold blood pressure level at which pharmacological therapy is introduced largely depends on associated cardiovascular risk facto rs and/or involvement of target organs. The JNC recommends a particula rly low threshold in patients with diabetes. Pharmacological treatment is usually initiated with a single drug. The choice of any one drug d epends on the patient profile and takes into consideration such charac teristics as age and associated risk factors or comorbidity. Some repr esent a contraindication for certain therapeutic classes (for example, asthma for P-blockers, renovascular hypertension for ACE inhibitors), while others are a specific or even 'compelling' indication (heart fa ilure, angina, renal disease, peripheral vascular disease etc.). This patient profiling is very precisely described in the new recommendatio ns. However, any such single drug therapy provides adequate blood pres sure control in no more than about 50 to 60% of patients. When the pat ient does not respond to the drug used or experiences side effects, su bstitution of a drug from another pharmacological class is recommended . In contrast, if the patient is a responder but blood pressure remain s above the target level, it is preferable to add a second drug from a class offering complementary action. The use of a combination therapy allows blood pressure control in more than 80% of patients. More auth ors are suggesting that combination therapy as first-line treatment ma y increase the number of responders and reduce the impact of counter-r egulatory effects occurring with single drug therapy (e.g. sodium rete ntion, or sympathetic activation). This alternative strategy is now ac knowledged in the recommendations.