A Selection of Ten Current Readings on Hypertension Available as Free Full-text

When first introduced in 1981, angiotensin-converting enzyme (ACE) inhibitors were indicated only for treatment of refractory hypertension. Since then, they have been shown to reduce morbidity or mortality in congestive heart failure, myocardial infarction, diabetes mellitus, chronic renal insufficiency, and atherosclerotic cardiovascular disease. Pathologies underlying these conditions are, in part, attributable to the renin-angiotensinaldosterone system. Angiotensin II contributes to endothelial dysfunction, altered renal hemodynamics, and vascular and cardiac hypertrophy. ACE inhibitors attenuate these effects. Clinical outcomes of ACE inhibition include decreases in myocardial infarction (fatal and nonfatal), reinfarction, angina, stroke, end-stage renal disease, and morbidity and mortality associated with heart failure. ACE inhibitors are generally well-tolerated and have few contraindications. (Am Fam Physician 2002; 66:473.) ANTIHYPERTENSIVE THERAPY Reading 3 Kaplan NM. Management of hypertension in patients with type 2 diabetes mellitus: guidelines based on current evidence. Ann Intern Med 2001 Dec 18; 135(12):1079-83. http://www.annals.org/issues/v135n12/full/200112180-00012.html University of Texas South western Medical Centre, Dallas, Texas, USA. ABSTRACT Hypertension and diabetes are becoming increasingly common. Most patients with both disorders have a markedly worsened risk for premature microvascular and macrovascular complications. The appropriate management of hypertension seen in almost 70% of patients with type 2 diabetes mellitus remains controversial. However, over the past few years, many randomized, controlled trials have provided guidance for more effective therapy. These trials have established the need for a lower goal blood pressure (<130/80 mmHg) than has previously been recommended. In addition, they have proven the efficacy of drugs from three major classes of antihypertensive agents; however, comparative trials have failed to show definite superiority of any particular class in either lowering blood pressure or reducing cardiovascular morbidity and mortality. To achieve therapy goals, multiple antihypertensive drugs are usually needed. On the basis of their apparent superiority in slowing diabetic nephropathy, angiotensin-converting enzyme inhibitors should probably be the first choice. Second and third choices should be a long-acting diuretic and a calcium-channel blocker or a beta-blocker, respectively. Attention should also be directed toward non-pharmacologic and pharmacologic control of hyperglycemia and dyslipidemia.Hypertension and diabetes are becoming increasingly common. Most patients with both disorders have a markedly worsened risk for premature microvascular and macrovascular complications. The appropriate management of hypertension seen in almost 70% of patients with type 2 diabetes mellitus remains controversial. However, over the past few years, many randomized, controlled trials have provided guidance for more effective therapy. These trials have established the need for a lower goal blood pressure (<130/80 mmHg) than has previously been recommended. In addition, they have proven the efficacy of drugs from three major classes of antihypertensive agents; however, comparative trials have failed to show definite superiority of any particular class in either lowering blood pressure or reducing cardiovascular morbidity and mortality. To achieve therapy goals, multiple antihypertensive drugs are usually needed. On the basis of their apparent superiority in slowing diabetic nephropathy, angiotensin-converting enzyme inhibitors should probably be the first choice. Second and third choices should be a long-acting diuretic and a calcium-channel blocker or a beta-blocker, respectively. Attention should also be directed toward non-pharmacologic and pharmacologic control of hyperglycemia and dyslipidemia. T H E S I N G A P O R E F A M I L Y P H Y S I C I A N A P R J U N 2 0 0 3 ; V O L 2 9 ( 2 ) : 4 5 C M E C A T E G O R Y I I I A _ S E L F S T U D Y Reading 4 Alderman MH. Hypertension control and kidney disease: some questions answered, many remain. JAMA 2002 Nov 20;288(19):2466-7. http://jama.ama-assn.org/issues/v288n19/ffull/jed20064.html Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, NY. (e-mail: [email protected]). SUMMARY The African American Study of Kidney Disease and Hypertension (AASK) compared renal outcomes at different blood pressure goals with alternate antihypertensive drugs in patients with hypertensive nephrosclerosis. The primary end point was change in the glomerular filtration rate (GFR) with a secondary clinical composite end point composed of end-stage renal disease (ESRD), a threshold decline in GFR, and all-cause mortality. The AASK serves as an important reminder of the need to make therapeutic decisions on the basis of clinical outcomes. Precise design and elegant implementation help to explain both the strengths and limitations of AASK. The results reported provide important information about renal function and blood pressure control during antihypertensive care in patients with hypertensive nephrosclerosis but insufficient data on both clinical renal effects and cardiovascular outcomes. Even though knowledge of physiological functions is useful for patients with hypertensive nephrosclerosis, it is not the whole story. Patients and physicians are best served when clinical decisions can be based on evidence of benefit measured by the duration and quality of life.