Antihypertensive therapy: pride and prejudice.
Investigators of hypertension can be proud of the indisputable successes achieved by antihypertensive therapy and of the correct methodology (randomized controlled trials) by which those successes have been proved. However, hypertension experts should not allow pride to turn into prejudice. Numerous aspects of antihypertensive treatment remain to be clarified. Indeed, that all goals of antihypertensive treatment have been achieved is clear prejudice. Although randomized trials have been essential for establishing the benefits of antihypertensive therapy, claiming that randomized trials are the only valid methodology for providing treatment benefits is another instance in which pride might turn into prejudice. Indeed, there is a large gap between trials and practice, and trials may both overestimate and underestimate the benefits of treatment. Furthermore, event-based trials are not the only valid type of trials, as is often claimed. If the goals of treatment are both to prevent events and avoid or reduce organ damage, then we need both event-based and organ damage-based types of trials. MEASUREMENTS OF SUCCESS: Assessment of the absolute risk and, consequently, calculation of the absolute benefit to be expected from treatment have appropriately been emphasized in recent guidelines for the management of hypertension as instruments to evaluate cost-effectiveness of treatment. However, there is reason for caution against an indiscriminate worship of this concept, because earlier treatment of milder, uncomplicated hypertension is an effective measure by which to prevent development of more severe and complicated hypertension, the treatment of which may be less successful, if success is measured by the residual mortality and morbidity of even well treated patients. BLOOD PRESSURE MEASUREMENTS: Finally, we are still ignorant of the best way to measure blood pressure in order to decide upon initiation and success of treatment. Supporters both of clinic blood pressure measurements and of home or ambulatory blood pressure monitoring have their own prejudices; the problem can only be solved by further research. As in Jane Austen's novel, before the happy end both pride and prejudice must be conquered.
Zanchetti
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Istituto di Clinica Medica Generale e Terapia Medica, Universita di Milano, Italy.
D000959:Antihypertensive Agents / Q000627:therapeutic use*; D018660:Blood Pressure Monitoring, Ambulatory; D002986:Clinical Trials as Topic; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000503:physiopathology
D000959:Antihypertensive Agents