Challenges in Management of Hypertension

Hypertension is the most frequent modifiable risk factor for heart failure and atherosclerotic cardiovascular disease. Its prevalence is reaching epidemic proportions in many developed and developing countries. However, in spite of advances in pharmacologic therapy, its rate of control worldwide is poor and its management is less than optimal. The following challenges face the scientific community, drug industry, health authorities and medical profession regarding the proper management of hypertension (1) improve cost-effectiveness, (2) improve blood pressure (BP) control, (3) target other cardiovascular risk factors, (4) regress target organ damage and (5) develop rational treatment. The most important challenge particularly in the developing world is to improve cost effectiveness of hypertension management. This challenge can be addressed by accurate classification of BP i.e. correct diagnosis of hypertension, avoiding initiating drug therapy in wrongly labeled hypertensives, giving priority to high risk patients, limiting laboratory tests to necessary ones, minimizing the number of office visits, maximizing lifestyle changes and starting treatment with lower cost medications.

Improvement of BP control depends upon better patient compliance. This requires both physician and patient education. Drug prescription should be simple with minimal number of tablets and long dosing intervals. The silent nature of hypertension, life-long treatment and need for follow-up should be stressed. High BP is commonly associated with other cardiovascular risk factors as obesity, dyslipidemia and elevated plasma glucose. Blood pressure alone is a weak predictor of cardiovascular risk. There is a need for global cardiovascular risk assessment and for addressing other risk factors beside high BP. New drugs that address many risk factors and high BP at the same time are needed.

The main goal of antihypertensive therapy is to prevent clinical events. Pharmacologic agents can, through both BP lowering and reduction of other risk factors, prevent target organ damage from the beginning and can regress target organ damage when it is present. Drugs that rapidly regress target organ damage (left ventricular hypertrophy, proteinuria, etc.) and attenuate the atherosclerotic process will have a special advantage. Some of antihypertensive drugs can prevent target organ damage independent of their BP lowering effect

The final and possibly the most difficult challenge in the management of hypertension is to find a rational rather than the current empirical approach for high BP control. The complexity of the pathophysilogic mechanisms controlling BP, its polygenetic nature and the interaction with environmental factors are responsible for the difficulty in finding a more rational treatment for hypertension. Candidate gene studies of BP suggest that choice of drugs can be based upon identification of genetic abnormalities involving RAAS, sodium channels, adrenergic receptors, alpha adducin and G-proteins. Vasodilator gene insertion and vasoconstrictor gene inhibition are still in the experimental phase. Very recently, the results of a phase 2 study suggested that an investigational vaccine against angiotensin II was safe and well tolerated in patients with mild to moderate hypertension. Treatment produced a significant reduction of ambulatory BP.