Monday, January 29, 2007

2006 in Hypertension

Let's have another quick look back at 2006. The field of hypertension did not progress as much as interventional cardiology, but it was exciting. The hypertension guidelines by the societies include a very important preventive arm allowing us to pick up pre-hypertensives and, if necessary, treat them as the present group of agents are effective and relatively free of side-effects.

An analysis of the data allows us to understand that in whatever state that we are in, the lower the BP the longer the life. Remembering that the oft quoted "normal " BP of 120/80mmHg is very much a population derived mean (within the 95% confidence limit), and that a BP of 120/80mmHg is still associated with a slight increased incidence of cardiac events and strokes.

The lower the BP the better, as that's where the incidence of MACCE is least except that the level of BP must be adequate to sustain normal life-style activities, without undue tiredness or dizziness (signs of inadequate circulation). This is one of the important message of 2006. Yr 2006 also saw the European view that the use of beta-blockers in the longterm (as sole therapy for hypertension) was associated with a slightly higher incidence of strokes and diabetes. This message essentially signalled the end of beta-blockers in hypertension, except in those patients where beta-blockers are use for anginal control, or arrhythmia control.

2006 also saw the establishment of ARBs as an important agent for the control of hypertension. Sometimes they are promoted as almost a "coughless ACE-I". Whether this is true or not, I do not know. I must say that there have been a few reports of mild cough even with ARBs. What perhaps is more important is that there is not enough data to tell me that ARBs are proven to be as good as ACE-I. Yes, in VALIANT, valsartan is equivalent and no better than Captopril. Well, my own opinion is that ARBs can be use to replace ACE-I when cough is a problem, but I would not go so far as to say that ARBs is better than ACE-I.

Nonetheless, 2006 saw the firm establishment of ARBs are an important part of the anti-hypertensive armanterium. 2006 also saw the use of drugs to regress LVH (a poor prognoostic marker in hypertension). Here again ARBs and ACE-I is well established. There are also better ways to pick up early signs of renal dysfunction in hypertension with the use of proteinuria or micro-albuminuria and the relationship of micro-albuminuria with GFR. Again, this seems to be reversible, if detected early with the use of ARBs. You see the targeting of hypertensive end organ damage and the role of the ARBs. I am almost certain that 2007 will see and hear more about ARBs. Whatever it is, 2006 was a good year for hypertension management.

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