Overview and perspectives of antihypertensive treatment.

An overview of antihypertensive trials shows that, when absolute rather than relative measures of benefit are considered, a large benefit is derived from treating severe hypertension, whereas in mild hypertension the rate of prevented morbid events is relatively small. However, a greater benefit is observed when a mildly elevated diastolic blood pressure is associated with other risk factors. Thus, antihypertensive therapy in the 1990s needs to be regarded as a component, albeit an important one, in a multiple-strategy approach to prevention and reversal of cardiovascular diseases. At a time when many different classes of antihypertensive agents are available, it is reasonable to ask whether some classes are more suitable than others for the treatment of patients with hypertension and concomitant risk factors such as dyslipidaemias and reduced glucose tolerance. It is well known that thiazide diuretics and beta-blockers have potentially adverse effects on lipid and glucose metabolism, that calcium antagonists and ACE-inhibitors are lipid neutral and that alpha-blockers have potentially favourable effects. Although the real impact of some of these changes is unproven, it is possible that one or more of the metabolic side effects of drugs such as diuretics and beta-blockers may offset some of the benefits of reduced blood pressure. Extensive testing of antihypertensive drugs with a favourable profile can be foreseen in the 1990s.