The goal of treating hypertension is to prevent the longterm morbidity and mortality associated with prolonged el-evations in blood pressure. To this end, antihypertensive ther-apy should be instituted in patients with blood pressures in ex-cess of 18.6/12.0kPa(140/90 mm Hg). The method and ag-gressiveness of treatment depends on several factors, including the absolute level of blood pressure, the presence of end-organ dam-age, coexisting medical conditions, and overall cardiac risk.

In patients with mild or moderate hypertension without organ damage, it is reasonable to attempt a trial of nonpharma-cologic therapy for 3 to 6 months. This therapy mainly con-sists of lifestyle modifications, including smoking cessation, weight reduction for overweight individuals, regular aerobic exercise, avoidance of alcohol, and restriction of dietary sodi-um intake (less than 6 g of sodium per day). These lifestyle changes may delay progression to sustained hypertension in pa-tients with "high-normal" blood pressure, aid in control of es. tablished hypertension, decrease of eliminate the need for pharmacologic therapy, and reduce other cardiac rish factors. These measures should also be instituted in patients with more severe hypertension [23.9/14.6kPa(£¾180/110 mm Ha)1, with multiple cardiac risk factors, or with evidence of end-or-gan damage; however, in these patients, pharmacologic thera-py should be started concurrently.

Controlling hypertension with medications has clearly been shown to decrease cardiovascular morbidity and mortali-ty, including the rate of stroke, myocardial infarction, heart failure, progressive renal disease, and all cause mortality. Many antihypertensive agents are now available for the treat-ment of high blood pressure. The decision of which agents to use in a particular patient must take into account individual pa-tient characteristics, comorbid conditions that may be affected by particular agents, possible interactions with other medica-tions the patients is taking, as well as convenience of dosing and cost of therapy. Medications should be started at low doses and titrated to higher doses as needed. More than half of pa-tients with mild to moderate hypertension can be controlled with a single antihypertensive medication. If the medication is in-effective at the maximal dose, a second agent should be added. In general, compliance is better with once daily medications.

The latest recommendation from the Joint National Com-mittee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) is that blockers and diuretics should re-main the initial drugs of choice for the treatment of mild to moderate hypertension unless a contraindication to their use exists or there is a clear indication for another 0gent. This rec-ommendation is based on randomized clinical trials that have demonstrated a decrease in morbidity and mortality with these agents. A generalized approach to treatment of the hyperten-sive patient is shown in the following Figure(Figure 3).

The JNC does, however, recognize that contain medica-tions have a real or theoretical advantage over blockers or di-uretics in certain situations or in certain populations. An indi-vidualized approach to drug selection is, therefore, encour-aged. For example, hypertension in African-Americans tends to respond better to treatment with diuretics or calcium chan-nel blockers than with blockers or ACE inhibitors. Patients with CAD should have their hypertension treated with block-ers, given the beneficial effects of these agents in this popula-tion. Similarly, patients with depressed left ventricular systolic function or overt heart failure are best managed with diuretics and ACE inhibitors. ACE inhibitors slow the progression of nephropathy in patients with diabetes and are the first-line agents in this setting. Sex and age do not appear to affect re-sponsiveness to antihypertensives, although the starting dosages of medications should be lower in the elderly popula-tion. Antihypertensive medications may aggravate certain co-existing medical conditions and must be used with caution in specific settings. For instance, blockers may induce bron. chospasm in patients with lung disease, ACE inhibitors and di-uretics may worsen renal insufficiency, and blockers and cal-cium channel blockers may acutely worsen heart failure or con-duction system disease (Table 16).

TABLE 16 Preferred and/or Problematic

Antihypertensive Agents in Selected Conditions

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