title: Angiotensin converting enzyme inhibition in clinical practice. The second step in "stepped-care": addition or substitution?
abstract: The step-wise addition of drugs in stepped-care therapy is based in good part on the need to control different pressor mechanisms in order to lower blood pressure effectively over a long period of time. These mechanisms include the primary mechanisms assumed to be responsible for the hypertensive process and subsequently, either the mechanisms missed by the first drug or the secondary mechanisms evoked by therapy. Although stepped-care therapy has proven effective for many, its rigid application misses the importance of control of systolic blood pressure and of reversal of cardiovascular hypertrophy as additional goals of treatment. Further, the addition of a second drug might mean, in some cases, that an ineffective first drug is continued for no apparent reason. Substitution rather than addition of drugs is a reasonable option. Moreover, the advent of newer drugs with multiple mechanisms of action suggests that a step-wise addition of drugs might not be needed if the list of first step drugs is reviewed with recent advances in mind.
authors.forename: R C
authors.initials: RC
authors.lastname: Tarazi
mesh_terms: D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001794:Blood Pressure; D004359:Drug Therapy, Combination; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000503:physiopathology; D014665:Vasodilator Agents / Q000627:therapeutic use
chemical_list: D000959:Antihypertensive Agents; D014665:Vasodilator Agents