Blood pressure control and benefits of antihypertensive therapy - Does it make a difference which agents we use?

This article debates the important question of whether blood pressure lower ing alone is responsible for the benefits accrued from antihypertensive the rapy as demonstrated in many multicenter randomized clinical trials with di fferent antihypertensive agents or whether there is evidence that some agen ts have special properties that result in benefits that go beyond those res ulting from lowering blood pressure. Over the past greater than or equal to 30 years, it has been demonstrated beyond any doubt that lowering blood pr essure in severe forms of hypertension, and more recently in systolic and e ven mild hypertension, will result in reduced incidence of stroke and slowe r progression of heart and renal failure. These effects have been easier to demonstrate in sicker patients, because enough end points may be counted i n the 3 to 5 years that these clinical trials last. However, risk attributa ble to high blood pressure comes, to a greater degree, from the much larger group of hypertensive individuals who have less severe forms of hypertensi on. Blood pressure lowering offers less protection from coronary heart dise ase, which is highly prevalent in hypertensive patients, than from stroke. With the introduction of agents such as renin-angiotensin system inhibitors or calcium channel blockers, it has been demonstrated that hypertensive va scular remodeling and endothelial dysfunction may be corrected. It has ther efore been suggested that benefits beyond blood pressure lowering may be ac hieved with the use of specific drugs to lower blood pressure. Although som e evidence suggests that this may be the case, it is difficult to extrapola te from mechanistic studies to prevention of hard end points in outcome tri als and vice versa. The question remains for the time being largely unanswe red.