- Email: [email protected]
Introduction: new directions in hypertension: beyond JNC VI
AJH
2003; 16:25S
Introduction: New Directions in Hypertension: Beyond JNC VI Thomas D. Giles
H
ypertension is one of the most common disorders in the United States, affecting approximately 50 million people.1 Hypertension is a major independent risk factor for cardiovascular and renal disease, increasing the risk of myocardial infarction, stroke, heart failure, and renal disease.1 Despite the well-established benefit of blood pressure (BP) reduction in reducing the risk of these clinical events, the rate of BP control remains poor.1 However, with the appropriate application of clinical data and utilization of treatment options, there is a considerable opportunity to increase levels of BP control and substantially reduce cardiovascular and renal morbidity and mortality. The purpose of this supplement is to review current approaches and consider new directions in hypertension management, including risk assessment, treatment goals, the use of antihypertensive agents and the importance of combination therapy, and considerations for the management of special populations. In the first article, I will review the definitions of hypertension and optimal BP from both a population and clinical viewpoint, and discuss the importance of BP as a test for vascular health and as a therapeutic target. In determining what BP goals should be, I will emphasize the importance of applying clinical trial data to treatment in light of individual patient characteristics, and will describe how these considerations are reflected in the current Joint National Committee (JNC) recommendations for the management of hypertension. In the second article, William C. Cushman, MD, will review the clinical trial evidence supporting the use of various classes of antihypertensive agents, including diuretics, -blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers, in reducing clinical events. Dr. Cushman will present results from several seminal clinical trials, including the recent Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT), which highlight the importance of using antihypertensive regimens that provide adequate BP control as well as end-organ protection when there is a compelling indication. Dr. Cushman will also review the results of the Losartan Intervention For Endpoint reduction in hyperten-sion (LIFE) trial with the angiotensin receptor blocker losartan. James L. Pool, MD, will discuss the role of
combination therapy, which most patients will require to attain their BP goals. By using complimentary mechanisms of action and lower doses of each agent, combination therapy is a safe and effective approach to achieving BP goals and reducing clinical events. The last three articles in this supplement address the management of hypertension in special populations. James R. Sowers, MD, will discuss treatment of patients with diabetes, a condition that is associated with multiple risk factors, including hypertension and an increased risk of cardiovascular and renal disease. Dr. Sowers will review the importance of aggressive treatment of multiple risk factors, including BP and the benefits of renin-angiotensin system (RAS) blockade in patients with diabetes. Leopoldo Raij, MD, will discuss renal disease, a condition that is highly prevalent in patients with hypertension or diabetes. Dr. Raij will review the key clinical trial evidence supporting the importance of aggressive BP control in patients with renal disease, focusing on trials in type 2 diabetes. He will also discuss the importance of interference with the RAS in inhibiting the progression of renal disease. Dr. Raij will review the results of several trials with angiotensin receptor blockers in patients with diabetic nephropathy, including the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) trial. In the final article, Keith C. Ferdinand, MD, will discuss the treatment of hypertension in the African American population, emphasizing the high prevalence of hypertension and high degree of morbidity and mortality in these patients. He will review the clinical trial data that address antihypertensive treatment of African American patients, and based on these results, will summarize treatment recommendations.
From the Department of Medicine, Louisiana State University School of Medicine, New Orleans, Louisiana. Address correspondence and reprint requests to Dr. Thomas D. Giles,
Department of Medicine, Louisiana State University School of Medicine, New Orleans, LA 70112; e-mail: [email protected]
© 2003 by the American Journal of Hypertension, Ltd. Published by Elsevier Inc.
Reference 1.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ and the National High Blood Pressure Education Program Coordinating Committee: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003;289:2560 –2571.
0895-7061/03/$30.00 doi:10.1016/j.amjhyper.2003.07.002
2003; 16:25S
Introduction: New Directions in Hypertension: Beyond JNC VI Thomas D. Giles
H
ypertension is one of the most common disorders in the United States, affecting approximately 50 million people.1 Hypertension is a major independent risk factor for cardiovascular and renal disease, increasing the risk of myocardial infarction, stroke, heart failure, and renal disease.1 Despite the well-established benefit of blood pressure (BP) reduction in reducing the risk of these clinical events, the rate of BP control remains poor.1 However, with the appropriate application of clinical data and utilization of treatment options, there is a considerable opportunity to increase levels of BP control and substantially reduce cardiovascular and renal morbidity and mortality. The purpose of this supplement is to review current approaches and consider new directions in hypertension management, including risk assessment, treatment goals, the use of antihypertensive agents and the importance of combination therapy, and considerations for the management of special populations. In the first article, I will review the definitions of hypertension and optimal BP from both a population and clinical viewpoint, and discuss the importance of BP as a test for vascular health and as a therapeutic target. In determining what BP goals should be, I will emphasize the importance of applying clinical trial data to treatment in light of individual patient characteristics, and will describe how these considerations are reflected in the current Joint National Committee (JNC) recommendations for the management of hypertension. In the second article, William C. Cushman, MD, will review the clinical trial evidence supporting the use of various classes of antihypertensive agents, including diuretics, -blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers, in reducing clinical events. Dr. Cushman will present results from several seminal clinical trials, including the recent Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT), which highlight the importance of using antihypertensive regimens that provide adequate BP control as well as end-organ protection when there is a compelling indication. Dr. Cushman will also review the results of the Losartan Intervention For Endpoint reduction in hyperten-sion (LIFE) trial with the angiotensin receptor blocker losartan. James L. Pool, MD, will discuss the role of
combination therapy, which most patients will require to attain their BP goals. By using complimentary mechanisms of action and lower doses of each agent, combination therapy is a safe and effective approach to achieving BP goals and reducing clinical events. The last three articles in this supplement address the management of hypertension in special populations. James R. Sowers, MD, will discuss treatment of patients with diabetes, a condition that is associated with multiple risk factors, including hypertension and an increased risk of cardiovascular and renal disease. Dr. Sowers will review the importance of aggressive treatment of multiple risk factors, including BP and the benefits of renin-angiotensin system (RAS) blockade in patients with diabetes. Leopoldo Raij, MD, will discuss renal disease, a condition that is highly prevalent in patients with hypertension or diabetes. Dr. Raij will review the key clinical trial evidence supporting the importance of aggressive BP control in patients with renal disease, focusing on trials in type 2 diabetes. He will also discuss the importance of interference with the RAS in inhibiting the progression of renal disease. Dr. Raij will review the results of several trials with angiotensin receptor blockers in patients with diabetic nephropathy, including the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) trial. In the final article, Keith C. Ferdinand, MD, will discuss the treatment of hypertension in the African American population, emphasizing the high prevalence of hypertension and high degree of morbidity and mortality in these patients. He will review the clinical trial data that address antihypertensive treatment of African American patients, and based on these results, will summarize treatment recommendations.
From the Department of Medicine, Louisiana State University School of Medicine, New Orleans, Louisiana. Address correspondence and reprint requests to Dr. Thomas D. Giles,
Department of Medicine, Louisiana State University School of Medicine, New Orleans, LA 70112; e-mail: [email protected]
© 2003 by the American Journal of Hypertension, Ltd. Published by Elsevier Inc.
Reference 1.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ and the National High Blood Pressure Education Program Coordinating Committee: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003;289:2560 –2571.
0895-7061/03/$30.00 doi:10.1016/j.amjhyper.2003.07.002