Clinicians' interpretation of the results and implications of the Hypertension Detection and Follow-up Program

I N THE LAST few years, a variety of nonpharmacologic therapies and newer antihypertensive agents have been advocated for longterm treatment of hypertension.‘*2 Proponents of these approaches frequently point to the variable risk of high BP, potential hazards of diureticbased antihypertensive therapy, and the “uncertain” benefit of treating patients with mild hypertension. 3-5 Individualization of treatment based on risk factor analysis, demographic features, hemodynamic characteristics, humoral factors, or volume status have been proposed in the hope of maximizing benefits and minimizing the risks of antihypertensive therapy. These obviously desirable goals have received considerable attention in the recent medical literature and, unfortunately, may overshadow several important observations made during the Hypertension Detection and Follow-up Program (HDFP) trial of Stepped Care (SC) treatment in hypertensive patients.“13 Nearly a decade has passed since the first Joint National Committee (JNC) on Detection, Evaluation, and Treatment of High Blood Pressure published their treatment recommendations.14 At that time, the benefit of drug therapy in middle-aged men with diastolic blood pressures (DBPs) of 105 to 129 mm Hg had been demonstrated during the Veterans Administration trial, but a reduction in coronary heart disease mortality and a favorable effect of drug treatment in patients with mild hypertension were not observed.‘51’6 This prompted the committee to recommend that treatment of patients with DBPs from 90 to 104 mm Hg “should be individualized, with consideration given to other risk factors.” Nonpharmacologic therapies (weight reduction, sodium restriction) were suggested as alternatives to drug treatment in light of the uncertain benefit of pharmacologic theraPYJ4 These recommendations were certainly reasonable at the time, since there was little published information available to document the efficacy of long-term drug treatment in producing a sustained antihypertensive response in ambulatory individuals with mild hypertension. Compliance was viewed as a major obstacle, and rightfully so, since there was concern that potential side effects and the inconvenience of continuous drug treatment would prompt treatment withdrawal in a high percentage of patients. The issues of compliance and toxicity in elderly patients were of major concern, since there was virtually no information about the safety of treatment in these individuals. All of these facts, when combined with the lack of documentation of a beneficial effect of BP reduction by drugs in patients with mild hypertension obviously influenced many physicians to withhold therapy. The pattern of treatment in patients referred to their usual sources of care in the community (Referred Care [RC] group) in the HDFP reflects this viewpoint.6 More recently, potential hazards of diureticbased antihypertensive therapy have been stressed because of the observation from the Multiple Risk Factor Intervention Trial (MRFIT) that aggressively treated men (specialized intervention [Si] group) with mild hypertension and abnormal resting ECGs had an increased coronary heart disease mortality when compared with a similar subset of men receiving care in the community (usual care [UC] group).” Unfortunately, the well-intentioned reviews that stress the lack of a statistically significant reduction in mortality of treated patients with mild hypertension in certain trials and the potential hazard of diuretic-based antihypertensive therapy after target organ involvement has developed as suggested in MRFIT can dissuade clinicians from instituting definitive antihypertensive therapy. Physicians may be per-