Metabolic and cardiovascular characteristics of hypertension. Familial aspects.

There are many convincing data showing that hypertension is an inherited syndrome of cardiovascular risk factors that clinically manifest at different times and occur independently of one another. These risk factors independently increase the potential for a patient to develop coronary heart disease, but when occurring together they appear to be synergistic in their ability to cause heart disease. It appears that in many patients high blood pressure may be a late manifestation of the disease process and may be indicative of a fairly advanced stage of disease. Moreover, it is possible that patients with the hypertension syndrome will develop coronary artery disease prior to the development of high blood pressure. We have recently demonstrated that when comparing cardiovascular risk factors in normotensive patients with a family history of hypertension to hypertensive patients with and without a family history of hypertension, there were no differences among the groups (Fig. 5). All three groups, however, were significantly worse off than normotensive subjects without a family history of hypertension. Thus, in terms of cardiovascular risk, these "normotensive hypertensive" patients were at a risk of developing heart disease equal to that of the hypertensive patients, the only difference being that there were not as many of such patients. The existence of the hypertension syndrome has some important diagnostic and therapeutic consequences. Because of our dependence on high blood pressure to isolate patients with the hypertension syndrome, it is unlikely that these patients will be treated. With an increased awareness of the presence of the hypertension syndrome and better screening techniques, it is likely that in the future we will be diagnosing and treating normotensive hypertension. We have demonstrated that when comparing normotensive hypertensive patients with truly hypertensive patients there are no differences in cardiovascular risk factors. The only difference between the groups is that the normotensive hypertensive patients do not have the high numbers (which may not be particularly important). It is thus likely that normotensive hypertensive patients have a risk of developing heart disease similar to that of truly hypertensive patients. For this reason, it is possible that normotensive patients with the hypertension syndrome will benefit from either conservative or pharmacologic therapy that reverses underlying cardiovascular risk factors without lowering the blood pressure. In treating high blood pressure in patients with the hypertension syndrome, it becomes important to select drugs that will reduce blood pressure while having a beneficial or at least a neutral effect on all of the other risk factors. Although the reduction in strokes and overall mortality in treated hypertensive patients warrants our continued enthusiasm for treating high blood pressure, an improved performance in reducing other cardiovascular risk factors adds to the benefits of antihypertensive therapy. Perhaps treating this disease as a syndrome rather than a number will result in a reduction in the incidence of coronary heart disease, as has been seen in the incidence of stroke.