Achieving blood pressure control in clinical practice

There are an overwhelming number of clinical trials that show that the main benefits of antihypertensive treatment are associated with blood pressure (BP)-lowering. Even small improvements in BP, or moving from a “prehypertensive” to a “normal” BP state, can have a dramatic effect on the progression of early-stage cardiovascular disease, and may actually regress the development of atherosclerosis. However, achieving adequate BP control can be very difficult, even under the scrutiny of a clinical trial setting; in general practice it is even harder. If physicians wait to the point at which arterial damage is well established, then we will always be striving to treat difficult or treatment-resistant patients. The difficulty in achieving BP-lowering is further aggravated by the involvement of a renin-angiotensin system-mediated counter-regulatory mechanism that offsets vasodilatory drugs and blunts dose response. Such issues raise the question of whether physicians should contemplate earlier intervention or initial combination therapy in order to prevent the evolution of damage, overcome the counter-regulatory mechanism, and minimize the need for multiple drug use in the long-term. Using combination therapy at an earlier stage would also remove heterogeneity in BP response and may reduce treatment resistance.