Update on the drug treatment of hypertension in patients with cardiovascular disease.

The management of the high-risk patient with hypertension has become more challenging in recent years. Drug therapy should be initiated earlier and at lower blood pressure levels in patients with coexisting cardiovascular or kidney diseases. The blood pressure goals of drug therapy are substantially lower when patients have concomitant heart or kidney disease or diabetes mellitus. Numerous clinical trials in tens of thousands of hypertensive patients with increased cardiovascular risk have demonstrated that the calcium antagonists are as effective and safe as diuretics, beta-adrenergic blockers, and renin-angiotensin blocking agents to prevent heart attack and stroke but not heart failure. Several recent studies also demonstrate that angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers are effective in preventing stroke, progressive renal insufficiency, and heart failure in higher risk patients with hypertension. To achieve the aggressive blood pressure goals in patients with cardiovascular disease, thoughtful combinations of additive or synergistic agents improve efficacy and tolerability and have become an integral part of the modern management of hypertensive patients with coexisting cardiovascular disease.