What are we really achieving with long-term drug therapy?

Hypertension-induced morbidity and mortality can be positively affected by antihypertensive treatment. This was first shown in malignant phase hypertension and it is now clearly established that not only total mortality but also morbidity from stroke, left ventricular failure, and progressive renal failure can be positively affected by pharmacological lowering of arterial pressure. Benefits of treatment for coronary artery disease are less obvious. In spite of the positive effects of antihypertensive therapy briefly mentioned here, recent data from several centers show that hypertension-induced risks in treated hypertensive patients are not reduced down to the level seen in comparable normotensive subjects. There could be several reasons for this. Some of the hypertension-induced cardiovascular changes are irreversible, or that antihypertensive pharmacological agents may have some adverse effects that would partially offset the advantages obtained through a reduction in blood pressure, or that treated arterial blood pressure usually has not been brought down to strictly normotensive levels. Therefore, the risks associated with hypertension have not been lowered to those seen in normotensive subjects. This latter point assumes particular significance in view of some recent suggestions that a too drastic lowering of blood pressure in hypertensive subjects may be associated with an increased risk, particularly for coronary artery disease mortality.