Critical overview of antihypertensive therapies: What is preventing us from getting there?

Hypertension is by far the most prevalent form of cardiovascular disease in the United States, affecting between 43 million and 50 million adults. Alt hough uncontrolled hypertension is well recognized as a modifiable risk fac tor associated with long-term target-organ damage, many are unaware they ha ve hypertension, as many as 50% are not receiving treatment, and an estimat ed 70% of those being treated do not achieve adequate blood pressure contro l. Why? Despite the effectiveness of antihypertensive therapy and considera ble evidence that morbidity and coronary disease have decreased between 195 0 and 1990, it appears that the progress made during those decades has not continued into the 1990s. Age-adjusted stroke rates for 1990 to 1994 rose s lightly, and the rate of decline in coronary disease during this same perio d has leveled off. Moreover, both the rate of end-stage renal disease and t he prevalence of heart failure increased during the early 1990s. The reason s for inadequate blood pressure control are numerous, including the multifa ctorial nature of hypertension; the presence of environmental factors such as diet, smoking, and concomitant drug therapy; poor adherence to therapy; insufficient therapeutic effort on the part of the treating physician; and adverse side effects of hypertensive agents.