Management of Hypertension [antikvár]

Preface Norman K. Hollenberg, MD, PhD As recently as 1966, thoughtful physicians with a strong interest in the problem of hypertension were able to maintain an "attitude of skepticism and restraint in accepting drugs that lower blood pressure as even a partial answer to the management of hypertensive disease" (Goldring and Chasis, 1966). One year later, the first report from the Veterans Administration Cooperative Study Group (1967) made it clear that drug treatment indeed reduced the morbidity of hypertension, at least in patients with a diastolic blood pressure over 115 mm Hg. These findings prompted a revolution in therapeutics. A major focus of this revolution has been the Importance of attempts to alter the natural history of chronic processes. No better example exists than the treatment of hypertension, where a series of carefully controlled trials has made it clear that treatment Is worthwhile (Amery et al, 1985; Helgeland, 1980; Hypertension Detection and Follow-up Program [HDFP] Cooperative Group, 1979a; Medical Research Council [MRC] Working Party, 1985; Multiple Risk Factor Intervention Trial Research Group, 1982; Report by the Management Committee, 1980; Smith, 1977; Veterans Administration \VA] Cooperative Study Group, 1967, 1970). Our major problem in the treatment of hypertension is that we do not provide symptom relief; rather, our goal is a change in natural history. Treatment that has as its goal a change in natural history, without providing symptom relief is fundamentally more difficult because of the compliance problem (Haynes et al, 1982). Obviously, symptom relief provides a spur to compliance, but there are no symptoms directly related to hypertension. The problem grows even more difficult as we try to treat mild hypertension, where the goal of changing natural history is clearly long term and the spur to compliance is even more limited. There has also been a continuing evolution in the drugs available for treatment and in recommendation concerning therapy—who to treat (Freis, 1982; Hollenberg, 1982; Kaplan, 1982; Laragh, 1982; Moser, 1982) and how to treat (Kaplan and Lieberman, 1982). Not surprisingly, that has been accompanied by an evolution in our expectations. The physician demands reliable evidence (for example, that a therapeutic agent is effective, provides predictable results, and is sufficiently well tolerated) that the patient will stay on treatment. Patients, aware of the enor-