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Treatment of Hypertension: A Clinical Epidemiologist's View

The majority of deaths attributable to hypertension are coronary artery disease (CAD) deaths and, consequenily, the prevention of CAD should be the primary aim of hypertension management. Recent meta-analyses confirm the results of the individual hypertension intervention trials, which demonstrated a disappointing shortfall in the observed prevention of CAD events and mortality from lowering blood pressure compared with the expected benefits. These trial results, rather than challenging the validity of the causal nature of the association between hypertension and CAD may be interpreted to suggest that the management of hypertension in the trials was suboptimal. The drugs used in the trials were almost exclusively thiazide diuretics and to a lesser extent β-blockers. Both of these drug groups have been shown to have adverse effects on lipid profiles—a pivotal risk factor for CAD. In addition to the effects on lipids, diuretics also adversely affect potassium, uric acid, glucose metabolism, and insulin resistance, all of which directly or indirectly affect the incidence of CAD. In the face of a major shortfall in the overall benefit from managing hypertension with diuretics and to a lesser extent β-blockers, it therefore seems more logical to recommend for the management of hypertension the use of agents with a more metabolic-friendly profile.