The broadening landscape for hypertension management

Several lines of evidence show that office blood pressure (BP) reduction can substantially decrease the risk of major cardiovascular events in hypertensive patients. It is also increasingly recognized that home and 24-hour ambulatory BPs provide additional prognostic information, and there is evidence to suggest that BP lowering over the 24-hour period is crucial for optimal risk reduction. However, BP is often difficult to control, even under the near-optimal conditions of clinical trials. Ideally, antihypertensive therapy should aim to control both office and out-of-office (i.e., 24-hour) BPs, and multiple risk factors in order to provide optimal cardiovascular risk reduction. This approach usually necessitates the use of polypharmacy with an attendant increase in costs and the risk of adverse events. For these reasons, increasing attention is being devoted to drugs that exert beneficial, BP-independent effects on target-organ damage or reduce the incidence of conditions (such as diabetes and metabolic syndrome) that are associated with high cardiovascular risk. Several studies have consistently shown that the incidence of new-onset diabetes is lower with angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and calcium antagonists than “older” drugs such as diuretics and beta-blockers. However, long-term studies examining target-organ protection may more fully illustrate the BP-independent benefits of specific antihypertensive agents.