From stepped care to tailored therapy.
In 1977 the National Heart, Lung and Blood Institute in the USA drew together a panel of experts as the first 'Joint National Committee' to provide guidelines on the detection, evaluation and management of hypertension. This was the birth of 'stepped care', which was internationally adopted, and consisted of: step 1--a diuretic; step 2--if step 1 is inadequate, add a beta-blocker; step 3--if step 2 is inadequate, add a vasodilator (e.g. hydralazine). With the evolution of a broader, multiple risk factor approach to the management of hypertension, and the development of newer agents, this simple system was modified during the 1980s. The relative importance of non-pharmacological intervention resulted in step 1 becoming drug-free, and alternative agents necessitated wider 'steps'. The interaction of hypertension with other coronary heart disease (CHD) risk factors, the disappointing effect of thiazides and beta-blockers on CHD events in intervention trials, and the increasingly large list of potential drug combinations meant that by 1989 several international consensus bodies no longer considered stepped care to be viable. Stepped care has been replaced by 'tailored therapy'. That is, based on an assessment of the patient's overall cardiovascular risk profile, the choice of first-line drug therapy has been broadened beyond diuretics and beta-blockers to include ACE inhibitors, calcium antagonists and selective alpha 1-blockers. Many hypertension experts are now of the opinion that, except in limited circumstances, diuretics and beta-blockers should only be used as second-line or third-line agents.
Poulter
N R
NR
Department of Epidemiology and Public Health, University College and Middlesex School of Medicine, London, UK.
D000959:Antihypertensive Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D001794:Blood Pressure / Q000187:drug effects / Q000502:physiology; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000503:physiopathology
D000959:Antihypertensive Agents