Future approaches to the treatment of hypertension in the light of results from recent trials.

In this review approaches to the treatment of hypertension were appraised by considering data from recent trials. Two main questions were asked: at what level of blood pressure is treatment justified, and which drugs should be used? It is now well established that increases in both systolic and diastolic blood pressure are correlated with an increased risk of cardiovascular disease, heart attack or stroke. However, since patients are often asymptomatic, treatment must be justifiable in terms of reversing the risk of cardiovascular disease. The Australian Therapeutic Trial demonstrated that therapy was beneficial in patients whose diastolic pressure was at or above 95 mm Hg before treatment. Three recent large studies (EWPHE, IPPPSH and MRC) have provided interesting data on the level of blood pressure at which to start treatment and the most appropriate drugs to use. In one, treatment in the elderly, which raises particular concern, has been investigated. The MRC trial compared bendrofluazide with propranolol and showed a reduction in the incidence of stroke; however, to prevent 1 stroke, 850 patients would have to be treated for 1 year. Nevertheless, the benefits of therapy were clearly greater when diastolic blood pressure was at the upper end of the range 90-110 mmHg. Myocardial infarctions, which account for more deaths than stroke in mild to moderate hypertensives, do not appear to be reduced by treatment, whether or not this includes a beta-blocker. This is difficult to reconcile with the established 'cardioprotective' action of beta-blockers post-myocardial infarction. Other important factors affecting cardiovascular disease are governed by the patient's life-style, especially whether or not the patient smokes.(ABSTRACT TRUNCATED AT 250 WORDS)