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Modern management of hypertension and heart failure: evidence and practice

Data on the clinical effectiveness of treatments for hypertension and heart failure are particularly extensive. This should result in the management of these conditions being among the most evidence based in medicine. However, as in many areas of medicine, a significant gap persists between the availability of evidence on effectiveness and the modification of routine clinical practice. This gap between evidence and practice is particularly important in the management of cardiovascular disease since coronary heart disease and stroke have become the two principal global causes of death and disability.1 

The relation between rising blood pressure and cardiovascular mortality is well known. The closer relation between systolic pressure and risk of cardiac events, however, is still underestimated. There is a fivefold increase in cardiovascular risk at high systolic pressures compared to the threefold increase with high diastolic pressure.2 It is still the case that many physicians concentrate principally on lowering diastolic pressure while not achieving systolic blood pressure targets.

This problem is further highlighted by the introduction of newer more aggressive blood pressure thresholds for diagnosis and targets for treatment. With these new thresholds, up to one third of the adult population in some countries would qualify as suffering hypertension.

Treating hypertension reduces the risk of cardiovascular mortality and morbidity. However, the scale of risk reductions possible in stroke prevention are reduced in the prevention of coronary heart disease.3 

Another group that has been under treated on a systematic basis are the elderly. As their absolute risk of events is much greater, the benefits to patients and to society would be much larger if they were more effectively treated.

### CURRENT PRACTICE IN HYPERTENSION

Data from the USA shows that there has been an improvement from the mid 1970s to the early 1990s in the number of hypertensive patients detected. However, there is …