[Cardiac protection and antihypertensive therapy: facts and theories].

After a brief introduction on the problems involved in the interpretation of long-term trials, the methods and the results of large clinical trials, on cardioprotection (defined as the ability of a drug to reduce mortality from all causes or fatal cardiovascular events) are reviewed, with the aim of providing useful clinical information for the treatment of the hypertensive patients. At the end of the review the author draws the following conclusions: The benefits of antihypertensive therapy reported in male patients suffering from severe hypertension are such that further controlled trials with placebo are not acceptable from an ethical point of view. The incidence of fatal and non fatal cardiovascular events is relatively low in mild uncomplicated hypertension but increases three-fold in the presence or organ involvement. A statistically significant reduction of mortality from all causes and of fatal cardiovascular events has been obtained in such patients by means of antihypertensive treatment in the Australian trial, contrary to the results of the MRC trial and the Oslo study. Furthermore, the HDFP trial has shown that mortality from all causes an fatal cardiovascular events are less frequent among patients in stepped care than among those in referred care. The EWPHE trial has demonstrated that antihypertensive treatment reduces non fatal complications and probably reduces mortality in elderly hypertensive patients. Diuretics, sympatholytics and beta-blockers have been used in the large trials on cardioprotection. When several trials prove the equivalence of drugs of different efficacy and safety, it is acceptable to extend the results obtained with such drugs to the therapeutic class they belong to. An example is represented by the results of the MRC and IPPPSH trials on cardioprotection with beta-blockers in male non-smokers suffering from mild-moderate hypertension.