Controversies in hypertension: mild hypertension, isolated systolic hypertension, and the choice of a step one drug.

The realization that cardiovascular morbidity and mortality increases in patients with mild elevation of either systolic or diastolic blood pressure has led to a consideration to treat millions of patients with mild diastolic or isolated systolic hypertension. The cost of administering a successful antihypertensive treatment program and the potential adverse effects of pharmacologic agents is of great concern. It has been emphasized that the risk of premature mortality differs in individual patients according to the number of associated cardiovascular risk factors at any level of blood pressure. This has led to a suggestion that only high risk patients be treated. However, a significant number of low risk patients with mild hypertension develop a more severe or complicated form of their disease even over a follow-up period of five to ten years. There is no good way to identify these patients. Trials of antihypertensive therapy suggest a beneficial effect of blood pressure lowering in mild hypertension. No trials of antihypertensive therapy in elderly patients with isolated systolic hypertension have been reported, but the elevation in systolic blood pressure appears to be an independent risk factor for cardiovascular mortality. Even the choice of the first step agent in treatment is debatable. Diuretics or beta blockers effectively lower blood pressure in the majority of hypertensive patients, particularly if modest dietary sodium restriction is achieved. The incidence of side effects, either symptomatic or biochemical, is similar but diuretics are unquestionably cheaper and probably more effective. Successful application of an antihypertensive treatment program may continue to reduce our unacceptably great incidence of cardiovascular disease.