Optimizing the pharmacologic treatment of hypertension: BP control and target organ protection.

Hypertension is a well documented risk factor for cardiovascular disease (CVD) and substantially contributes to the global burden of disease. Different drug options exist for combination therapy as part of an overall control of risk factors in order to decrease the absolute risk of CVD. Several guidelines in recent years have tried to set up recommendations to increase the proportion of subjects in acceptable BP control from high-risk groups. Some conventional drugs are still very important in modern hypertension treatment, e.g. low-dose thiazide diuretics. However, newer compounds have added to the list of useful agents to be used as monotherapy or in combination therapy for improved target organ protection, e.g. the calcium channel antagonists and ACE inhibitors. The role of beta-adrenoceptor antagonists (beta-blockers) has changed somewhat as a result of critical comments from recent meta-analyses. Currently, therefore, beta-blockers are recommended less often for primary prevention and monotherapy, but should still be used for secondary prevention, combination therapy, and for symptom relief. Finally, the new angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) are still rather expensive, but have been increasingly documented in clinical trials for patients with essential hypertension. One controversial aspect is whether ARBs are better, worse, or equal to standard therapy with an ACE inhibitor for cardiovascular protection. BP remains poorly controlled in a large number of hypertensive patients and there is a greater need to control all relevant CVD risk factors in such patients. Therefore, different drugs are needed in order to be used in evidence-based synergistic and cost-effective drug combinations.