prevention of hypertension

Because the value of treating hypertension is no longer in question,
the most important remaining issue is how to do it. Although lifestyle
modification can be effective in some hypertensive patients, no clinical
trial data exist that have shown that a nonpharmacologic regimen will
reduce morbidity and mortality (29,30). Lifestyle modification, especially
weight loss and sodium restriction, will reduce BP modestly in
many patients in the short term (31). Few studies have shown that even
those who can adhere to a diet and achieve BP reduction will maintain
that benefit for more than 18–24 mo. In fact, in the only clinical
trial that ever compared morbidity and mortality in those treated with
lifestyle modifications alone vs those treated with lifestyle modification
and pharmacologic agents—the Treatment of Mild Hypertension Study
(TOMHS)—showed that the combination of drugs and lifestyle regimen
reduced events statistically significantly better than successful lifestyle
modification alone (12). Nonetheless, weight loss, physical activity,
moderation of alcohol and salt intake, and attempts to reduce and cope
with stress should all be strongly and unambiguously recommended to
hypertensive patients (24). The clinician and the patient, however,
should know that for the overwhelming majority of those treated to
lower BP and prevent cardiovascular events, pharmacologic agents will
be required.
The majority of the clinical trials done recently have addressed the
issue of which drugs to use (9–13,20,21,28) (Table 1-5). For the most
part, these studies have focused on which drug to begin therapy, ignoring,
perhaps, the fact that most hypertensives will require more than
one agent to reach a patient’s goal.
The first major studies that compared initial therapy addressed
whether regimens beginning with diuretics were as good as those beginning
with 􀁠-blockers (6,9,10,21). With the exception of older hypertensive
patients, in whom diuretics are clearly superior (21), there is no
evidence that either class of agents prevents cardiovascular events better
than the other (13).