High blood pressure (BP) or arterial hypertension (HTN) is set to remain the single most important preventable cause of premature death worldwide over the next 2 decades. (JACC 2006; 48:1698). HTN if left untreated for too long, or combining/ Interacting obesity, diabetes, hyperlipidemia, inevitably resulted in increasing total mortality/morbidity of cardiovascular system, i.e. stroke, coronary heart disease, heart failure and end-stage renal disease. (Lancet 2007;370:591) High BP appears to be most important attributable cause of total death worldwide 2001, far exceeds the risk factors, such as cigarette smoking and hyper cholesterolemia, despite economic condition of the countries. ( Lancet 2006; 367:1747)
Early Reduction in BP is able to decrease risk of subsequent cardiovascular disease (CVD) events. (Circ 2006; 114: 2580) Most of the opinions from experts and guideline in treating high BP points out that benefits of anti- HTN therapy are mainly due to BP lowering per se,( J Hypertens 2007;25:1751) or central pressure lowering per se should be more correctly, rather than the way by which it is lowered. ( Lancet 2007;370:845) Early reduction of BP, no matter what medication chosen or allocated to will reduce risk of stroke by 45% and CHD by 35%. (Poulter N. Late Breaking ASCOT. ISH Meeting. Oct. 18, 2006 )
Thiazide diuretics have been, are and will be a cornerstone in the anti-HTN arena. Most the guidelines recommended thiazide diuretics be used alone as initiative treatment or in combination with other classes of drug. Thiazide diuretics combing a rennin-angiotensin system (RAS) blocker is the good combination, if not the best. (J Hypertens 2007;25;25, 2007;25:1101). However, since hypertension may very likely share same pathophysiologic mechanism with type 2 diabetes (T2D), and most HTN patients (pts.) will inevitably develop T2D later in his or her life, first-line use of thiazide diuretics in T2D pts. or pts. at risk for T2D should be discouraged. As far as diabetes is concerned, RAS blocker is good choice to hinder or delay the development of new onset diabetes.
NHANES III revealed that more than 50% of HTN pts. may have already had hypercholesterolemia with LDL-C >130mg% or 3.4mmol/L. Choosing a suitable drug(s) to lower blood pressure but not to alter lipid metabolism is also an important issue. Since hypercholesterolemia or elevated LDL-C is found to enhance the development of HTN (J Hypertens 2007; 25: 2051, Circ 1999; 100: 2131), adding a statin in addition to anti-HTN treatment is rational and will provide benefits beyond BP reduction. (JACC 2005; 45:813, JACC 2006; 48:849, Lancet 2007; 370: 591) COURAGE trial just confirmed this benefits from aggressive medical treatment which including statins. (NEJM 2007; 356: 1503, JACC 2007; 50: 1598) |
