Mild hypertension: critical analysis of different therapeutic approaches
Ray W. Gifford, MDAddress reprint requests to Department of Hypertension and Nephrology, The Cleveland Clinic Foundation, One Clinic Center, 9500 Euclid Avenue, Cleveland, Ohio 44195.
In 1988 the fourth Joint National Committee (JNCIV) issued new guidelines for the detection, evaluation, and treatment of hypertension. Pharmacologic along with nonpharmacologic therapy is indicated for hypertensive patients whose diastolic blood pressures average ≥95 mmHg over a period of time and for patients who have a diastolic blood pressure of 90 mmHg to 94 mmHg with evidence of target organ disease and/or other major risk factors. In the absence of target organ disease and/or other major risk factors, a trial of nonpharmacologic treatment is recommended for patients with a diastolic blood pressure of 90 mmHg to 94 mmHg. The JNC IV report recommends initiating pharmacologic treatment with any one of the following classes of drugs: diuretics, beta blockers, calcium channel blockers, or ACE inhibitors. In general, diuretics and calcium channel blockers are especially indicated for elderly and black patients and beta blockers and ACE inhibitors for young and white patients, but there are many exceptions. In selecting the appropriate step-one agent for a given patient, the therapeutic “two-for-one” concept is emphasized whereby one antihypertensive drug may also be beneficial for a coexisting condition. Examples are: diuretics or ACE inhibitors in congestive heart failure; calcium channel blocking drugs or beta blockers in angina pectoris or paroxysmal supraventricular tachycardia; and beta blockers for migraine headache or senile tremor.