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In most hospitals, it is cardiologists to whom patients with difficult hypertension are referred. Although these patients may appear a distraction from the sicker patients in cardiac clinics, cardiologists will recognise hypertension as the most common cause of strokes, the most common reversible cause of cardiac failure, and more important than hypercholesterolaemia as a preventable cause of ischaemic heart disease in diabetes.1 The purpose of this review is to let cardiologists reap some of the fruits of the last two years in the hypertension world, where we now have more answers than questions about the objectives of treatment and how to achieve these, and (with a little didactic licence) we can relate treatment choices to a logical understanding of hypertension itself.
Key points
Community surveys show that less than 10% of patients have a blood pressure at target
Recent outcome trials show that achieved blood pressure is much more important than choice of initial drug in preventing stroke and myocardial infarction. Therefore strategies for optimising blood pressure control in the individual patient are paramount
In more than 90% of patients, the cause of hypertension remains unknown
Primary hyperaldosteronism (Conn's syndrome) accounts for at least 5% of hypertension, and usually presents with normal plasma electrolytes
Numerous molecular variants are being found which contribute a small amount to the development of hypertension. Patient response to different drugs may depend in part on which of these is inherited
The main determinant of response pattern is the patient's age. This probably reflects the dominant role of the renin system in blood pressure regulation
Younger patients have relatively high renin concentrations and respond well to drugs which suppress the renin system—ACE inhibitors, angiotensin receptor blockers (A), and β blockers (B)
Older patients have low renin concentration, and respond well to drugs which do not …