General Approach to Treatment

Ö As is the case with dyslipidemia and other cardiovascular conditions, drug selection for the management of patients with hypertension should be considered as adjunctive to nonpharmacologic approaches for BP lowering. Previous clinical research has established the relative value of using individual antihypertensive drugs versus placebo to achieve reduction in morbidity and mortality by lowering BP. However, as newer antihypertensive agents are developed, it is difficult to justify the comparison of newer agents to placebo on ethical grounds. Consequently, contemporary large outcome-based, multicenter trials have been designed to compare one specific agent-based therapy (along with options to add others) versus another agent-based therapy (along with options to add others of a different class). These attempts at "head-to-head" comparisons and meta-analyses of multidrug regimen trials have, in general, provided evidence supporting the position that the main benefits of pharmacologic therapy are related to the achievement of BP lowering and are generally largely independent of the selection of an individual drug regimen. Inherent in this position is the realization that nonpharmacologic approaches alone are rarely successful in attain ing target BPs, and multidrug therapy (sometimes as many as three or more agents)

is necessary for most patients with hypertension. While JNC 7 focuses on utilizing BP levels in determining the threshold and target for treatment, the European Society of Cardiology also incorporates total cardiovascular risk in determining thresholds for treatment. This approach results in a "flexible" definition of hypertension which is dependent on an individual's total cardiovascular risk. While acknowledging that there are several approaches currently employed to manage patients with hypertension, this chapter will use as its basis the JNC 7 guidelines while recognizing important changes outlined within the American Heart Association Guidelines.

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