Siegel the best pharmacological treatment for these patients will have major morbidity and mortality consequences, as well as important implications for the cost of medical care. Currently, US national hypertensive treatment is at odds with published guidelines from national bodies. In older studies of different populations and different time periods, there has been an increased use of calcium antagonists and ACE inhibitors, with a parallel decline in the use of thiazide diuretics and β-blockers (Siegel and Lopez 1997). This change in antihypertensive drug use occurred despite recommendations from The Fifth and Sixth Reports of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V and VI) that hydrochlorothiazide and β-blockers be used as first-choice agents if there are no other specific indications. This is because they have been shown in long-term controlled clinical trials to reduce cardiovascular morbidity and mortality as well as or better than other classes of antihypertensives, and they are far less expensive (JNC 1993, 1997). The US is not alone in this problem. Studies performed in Canada and the United Kingdom of patients newly treated for hypertension show variability in the choice of initial medication. ACE inhibitors and calcium antagonists were more commonly prescribed in the Canadian province of Saskatchewan (Bourgalt et al 2001), whereas diuretics or β-blockers accounted for 54% of new prescriptions in Britain (Walley et al 2003). In the US, data from the National Ambulatory Care Medical Surveys of office-based physicians has been used to evaluate antihypertensive treatment from 1980 to 1995 (Nelson and Knapp 2000). Trends in this study included a decrease in diuretic use and an increase in calcium antagonist and ACE inhibitor use. More recently, a study of Maine Medicaid databases for 1994, 1997, and 1999 reported high use of ACE inhibitors and calcium antagonists (Clause and Hamilton 2002). Barriers to blood pressure control Why only a small proportion of hypertensives achieve recommended blood pressure reduction targets is likely to be multifactorial including patient belief systems dismissing hypertension as a significant medical problem, lack of consistent medical follow-up, provider failure to adjust drug regimens to achieve control, medication side effects and Table 1 Impediments to and potential strategies for effective blood pressure control Impediments Possible interventions Patient-based Attitudes about hypertension Medication side effects Medication cost Medication adherence Provider-based Knowledge Access Awareness Motivation Societal-based Awareness Access to care 10 Education at the community and individual level concerning consequences of hypertension Use of medications with fewer side effects Education of and treatment for sexual side effects Use of diuretics and other generically available medication Less frequent dosing of medications Promotion of pillboxes Combination medications Methods to increase ease of medication renewal (ie, telephone or computer-linked) Rewards for higher adherence and lower blood pressure Conferences Academic detailing Computer-based algorithms Publication of clinical trials Use of physician extenders Group visits Work site care Expansion of health coverage Computer based reminders Incentives for health providers and managers Public education campaigns Community-screening programs Work-based programs Expansion of health coverage (private and government financed) Vascular Health and Risk Management 2005:1(1)