Hypertension in practice: towards the year 2010

D Gareth Beevers

This review is based on the premise that the majority of hypertensive patients are managed by primary healthcare teams comprising both doctors and specialist nurses. It attempts to provide clinical guidance, taking into account the large number of important long-term outcome studies published since the millennium. It is now clear that clinical decisions should be made on the basis of the systolic rather than diastolic blood pressure. It is also now increasingly evident that blood pressure readings taken at home are more predictive of outcome than isolated raised readings taken in the clinic. Patients should now be encouraged to obtain their own blood pressure machine in order to provide reliable readings in a familiar nonstressed setting. The threshold for starting antihypertensive medication depends on the patients’ total cardiovascular risk, rather that just the height of the blood pressure. In particular, blood pressure should be managed aggressively in patients who have concurrent diabetes mellitus. There is now good evidence that such treatment is of value in all ages, including patients over the age of 80 years. There has been radical change in the choice of fi rst-, second- and third-line drugs, with a steady decline in the use of β-blockers and an increase in the popularity of the angiotensin-blocking drugs. These agents are now the fi rst-line choice in younger patients, those with diabetes and/or chronic renal impairment. The long-term outlook for a patient is more closely related to the quality of blood pressure control at follow-up, rather than the severity of the hypertension in the fi rst place. Well-organized clinical care, with an increasing involvement of nurses, can achieve the required targets.