Is high blood pressure a late manifestation of the hypertension syndrome?

Because hypertension has generally been defined as a disease of elevated sy stolic and diastolic blood pressure, the goals of treating hypertension hav e been simply to normalize the blood pressure. It was believed that if norm al blood pressure were achieved, patients with hypertension would experienc e significant reductions in the incidence of associated cardiovascular even ts. However, studies to assess cardiovascular events in patients with hyper tension have repeatedly demonstrated that reducing blood pressure results i n very impressive reductions in cerebrovascular disease but in reductions o f only about 16% in coronary artery disease, which is far lower than what w as statistically predicted from the reductions in blood pressure. Although there are probably several reasons for the poor rate of reductions in the i ncidence of coronary artery disease, one of the most compelling appears to be the realization that hypertension is not simply a disease of numbers but rather a complex inherited syndrome of cardiovascular risk factors, all of which contribute to the development of heart disease in these patients. In cluded in the hypertension syndrome are abnormalities of lipid profile and insulin resistance, changes in renal function, endocrine changes, obesity, abnormalities of coagulation factors, and changes in the structure and func tion of the left ventricle and of vascular smooth muscle in the vasculature . In many patients, high blood pressure is a late manifestation of this dis ease process and is preceded by some or all of the associated cardiovascula r risk factors. This paradigm suggests that therapeutic strategies for hype rtension should be interventions that target both the hemodynamic and nonhe modynamic mechanisms of this syndrome to more completely reduce cardiovascu lar morbidity and mortality in patients with hypertension. Am J Hypertens 1 999;12:215S-223S (C) 1999 American Journal of Hypertension, Ltd.