Differential effects of antihypertensive drugs on hypertension: associated risk factors.

The primary aim of the management of hypertension should be to prevent coronary heart disease. Antihypertensive treatment should have a beneficial effect on the risk factors associated with coronary heart disease, particularly hypertension, dyslipidemia, hyperinsulinemia, and/or glucose intolerance. Other important risk factors include central obesity, left ventricular hypertrophy, hypokalemia, and smoking. In patients genetically predisposed to essential hypertension, metabolic alterations characterized by insulin resistance, hyperinsulinemia, and dyslipidemia tend to occur already before the development of hypertension, obesity, or redistribution of body fat. In the treatment of normotensive or borderline hypertensive diabetic patients, angiotensin-converting enzyme (ACE) inhibitors have shown superiority to other agents due to their antiproteinuric effect and their beneficial influence on the glomerular filtration rate. ACE inhibitor treatment of patients with overt diabetic nephropathy has been reported to reduce the risk of mortality and the need for dialysis or transplantation. Beta blockers and thiazide diuretics are still the 'gold standard' of antihypertensive therapy in non-diabetic patients, as they offer at least some prognostic benefit, while the influence of the newer antihypertensive drugs on morbidity and mortality in these patients is not yet known. Nevertheless, since practicing physicians have to treat patients rather than statistical numbers, the current trend towards a more individualized selection, including the newer antihypertensive drugs with consideration of their metabolic, cardiac, and renal action profile, is also difficult to rebut. ACE inhibitors and most calcium antagonists have already evolved as the preferred drugs for the treatment of hypertension in diabetics due to their favorable effects on some of the cardiovascular and renal risk factors.