Symposium on the Update on the Management of Hypertension (2004)

In May of 2004 a symposium was held in Washington, DC to update the management of hypertension. The symposium was telecast to more than 200 hospitals and health care facilities in the United States. The speakers included Dr. Marvin Moser, Clinical Professor of Medicine, Yale University School of Medicine, New Haven, CT; Dr. Thomas Pickering, Professor of Medicine, Columbia University School of Physicians and Surgeons, New York, NY; Dr. Vasilious Papademetriou, Professor of Medicine, Georgetown University School of Medicine, Washington, DC; and Dr. Domenic Sica, Professor of Pharmacology and Medicine, Virginia Commonwealth University, Richmond, VA. This supplement to The Journal of Clinical Hypertension reports their presentations. The first paper summarizes the results of recent clinical trials that evaluated different therapies in the management of hypertensive cardiovascular disease. Large-scale comparative clinical trials have provided new information regarding the relative merits of various antihypertensive agents and additional information confirming that lowering blood pressure will dramatically reduce the occurrence of coronary heart disease (CHD) events, heart failure, stroke, and progression of renal disease. Results of a 40,000 patient double-blind study, the Antihypertensive Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), comparing diuretics to a calcium channel blocker and an angiotensin-converting enzyme (ACE) inhibitor are reviewed. CHD events, the primary outcome, were similar among the three categories of drugs tested. The use of diuretics, especially in the black and elderly population, resulted in a greater decrease in blood pressure than with the ACE inhibitor; this may account for the finding of fewer strokes and episodes of heart failure with diuretics when compared with the ACE inhibitor. In addition, heart failure events were lower with diuretics than with the calcium channel blocker. Results were similar in diabetics and nondiabetics. New-onset diabetes was, however, more prevalent in the diuretic-treated patients. The Second Australian National Blood Pressure (ANBP2) study compared an ACE inhibitor and a diuretic in an unblinded study. The results of this trial indicated that ACE inhibitors were marginally better in preventing CHD events in males when compared with a diuretic. These trials, as well as others, were considered in the recommendations of the Seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Highlights of this report include the classification of blood pressures of 120–139/80–89 mm Hg as prehypertension and the recommendation of thiazide diuretics as initial therapy for most hypertensive patients, with other agents used in special or compelling situations. In addition, a goal of <130/80 mm Hg was set for patients with diabetes, renal disease, and heart disease, compared with a goal of <140/90 mm Hg for patients without these comorbidities. The report also recommended for the first time that combination therapy with two different agents represented appropriate therapy for patients with stage 1 hypertension with diabetes or renal disease and for patients with stage 2 hypertension (blood pressures >160/100 mm Hg). Dr. Papademetriou discusses the evolution of left ventricular hypertrophy (LVH) to heart failure in hypertensive patients. It is clear that elevated blood pressure results in both left atrial enlargement and LVH if it is uncontrolled and that LVH represents an important independent risk factor for CHD events and heart failure. Treatment of hypertension with any of the antihypertensive drugs other than vasodilators will result in regression of LVH in a large percentage of patients if blood pressure is controlled. Concerns that regression of hypertrophy would not result in improved outcome have been answered in recent studies that are reviewed by Dr. Papademetriou. CHD events are reduced in patients who experience regression with treatment when compared with patients whose LVH does not regress. Therapy of heart failure in hypertensive patients and the fact that untreated elevated blood pressure is still the leading cause of heart failure in the United States are discussed. Emphasis is placed on multiple therapy with agents that block the renin-angiotensin system plus a diuretic, a β blocker, and in many cases, digoxin. Dr. Thomas Pickering reviews data on hypertension and the elderly with special emphasis on the accurate diagnosis and variability of blood pressure in this population. It is now clearly recognized that an elevated systolic blood pressure poses a greater risk for cardiovascular events than diastolic blood pressure elevations. It is also recognized that in the elderly, systolic hypertension is the primary reason for treatment. While many physicians recognize this, there are data to indicate that elevated systolic pressures are not being treated effectively. Dr. Pickering summarizes the results of the clinical trials that treated both systolic and systolic/diastolic blood pressure elevations in the elderly and that have demonstrated a dramatic reduction in CHD events, heart failure, and stroke. It is clear from numerous clinical trials in this population that treatment is beneficial and that more patients should be treated more effectively. Finally, Dr. Sica reviews drug considerations in the management of renal disease and hypertension and focuses attention on the variability of creatinine levels and renal function in hypertensive individuals—a subject that until recently has not been highlighted. He discusses the importance of drug clearance and excretion with the various categories of antihypertensive agents. A careful review of the literature reveals that patients with chronic renal disease have an improved outlook when blood pressure is lowered and suggests that chronic renal disease may be prevented with adequate treatment of blood pressure before its development. Dr. Sica reviews in detail the use of thiazide diuretics, ACE inhibitors, and angiotensin II receptor blockers, and the importance of proteinuria in kidney disease. He discussed the benefits of using agents that block the renin-angiotensin system in patients with renal impairment. The mode of elimination of many of the antihypertensive drugs is an important consideration when evaluating drug dosages and usage in the renally compromised patient. Blood pressure control with levels <130/80 mm Hg remain the cornerstone of therapy in the chronic kidney disease patients. Achieving this goal in more patients will prevent the rapid increase in end-stage renal disease. This symposium updates the management of hypertension in elderly patients and patients with heart failure and renal disease.