Modification of stepped care approach to antihypertensive therapy.

"Stepped care" is a standardized recipe for uniform treatment of hypertension that has produced useful information on the effectiveness of long-term antihypertensive therapy. However, experience with this unimodal approach to treatment has also revealed its weaknesses. Conceptually, stepped care ignores the possible importance of the means by which blood pressure is reduced and leads to drug overuse since there is no systematic plan for drug subtraction or dose reduction. Moreover, stepped care has never been critically tested against other algorithms. From a practical standpoint, stepped care has never been shown to protect from coronary events, the major burden of hypertension; in several studies, these events may have been increased, probably by the inclusion of a diuretic in the regimen. Such results indicate that a single recipe for all, based on a single process hypothesis, may be hazardous. A critical current issue is the question of whether it matters how the blood pressure is reduced. Thus, diuretics reduce pressure by lowering volume and flow whereas the modern agents, converting enzyme inhibitors and calcium influx inhibitors, reduce pressure while actually improving flow to the target organs. With the availability of more potent and palatable agents with different specificities, and with the increasing awareness of the heterogeneity of essential hypertension and the means to demonstrate it (that is, renin profiling), treatment strategies should be designed and tested in which single drug types are selected for their specificity and their long-term benefits evaluated. In a proposed model, beta blockers or converting enzyme inhibitors are given first to patients with medium or high renin levels and calcium blockers or diuretics to patients with low renin levels. The likely possibility that preservation of flow is a more relevant goal than reduction of pressure per se requires critical examination.