Adult hypertension: reducing cardiovascular morbidity and mortality.

(1) Since our last review of treatments for arterial hypertension in 1999 (Prescrire International no.41), many new data have been published and new antihypertensive drugs have appeared on the market. (2) The working definition of hypertension is unchanged, namely blood pressure of at least 160/95 mm Hg in the general population, and at least 140/80 mm Hg in patients with diabetes and a history of stroke; these figures must be found on several occasions using a standardised method, with the patient at rest. (3) The goals of antihypertensive therapy are to reduce mortality and cardiovascular events, and not simply to drive blood pressure below a fixed (and often controversial) threshold. (4) Some drug and non drug interventions have a positive risk-benefit balance in the long term. (5) When antihypertensive drug therapy is needed, trials based on clinical endpoints show that it is best to start treatment with a single drug. (6) New data support the use of certain thiazide diuretics (chlortalidone, or hydrochlorothiazide if chlortalidone is not available) as first line treatment for most hypertensive patients, including non diabetic adults, diabetic adults, elderly subjects (over 65 years), and stroke patients. Some betablockers and angiotensin-converting-enzyme inhibitors (ACE inhibitor) are second-line alternatives. (7) Assessment of other antihypertensive drugs has also progressed since 1999, including indapamide (thiazide-like diuretic), amlodipine, diltiazem and verapamil (calcium channel blockers), lisinopril (ACE inhibitor), and losartan and valsartan (angiotensin II antagonists). However, these drugs are not as thoroughly evaluated as thiazide diuretics, betablockers and some ACE inhibitors.