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STATE-OF-THE-ART PAPER

Recent hypertension trials

Implications and controversies

Department of Cardiovascular Sciences, University of Leicester School of Medicine, Leicester, United Kingdom

Manuscript received September 8, 2004; revised manuscript received October 16, 2004, accepted October 18, 2004.

^* Reprint requests and correspondence: Dr. Bryan Williams, Professor of Medicine, Clinical Sciences Building, Leicester Royal Infirmary, P.O. Box 65, Leicester LE2 7LX, United Kingdom (Email: bw17{at}le.ac.uk).

The pharmacologic treatment of hypertension has been extensively studied by clinical trials. These studies have provided definitive evidence of a treatment benefit, and the weight and consistency of the clinical evidence has led to uniformity in many aspects of treatment recommendations worldwide. However, controversies remain—in particular, whether specific classes of drug therapy offer benefits for cardiovascular disease prevention beyond the expected benefits of blood pressure lowering per se. Updated large-scale epidemiologic studies and the meta-analysis of clinical trial data have better informed this debate and emphasized that the main driver of clinical benefit from blood pressure-lowering therapy is the magnitude of blood pressure reduction and perhaps the speed at which it is achieved. However, clinical trials are of short duration, and there are more marked drug-specific differences in intermediate cardiovascular structure, functional, and metabolic end points. The challenge is to interpret their significance with regard to longer term outcomes. Finally, although blood pressure lowering is undoubtedly beneficial, the concepts of single risk factor intervention and arbitrary blood pressure thresholds and treatment goals are being challenged by the recognition that the real target is cardiovascular disease risk. Undoubtedly, the most effective way to "go beyond blood pressure" is to add a statin.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   AF = atrial fibrillation   ARB = angiotensin receptor blocker   CCB = calcium channel blocker   CHD = coronary heart disease   CI = confidence interval   CVD = cardiovascular disease   HF = heart failure   MI = myocardial infarction

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