Treatment of mild hypertension. Decision before drugs
S. C. Zell and C. K. Lardinois
Department of Internal Medicine, University of Nevada School of Medicine, Reno.
The treatment of mild hypertension by the primary-care physician requires
an understanding of its natural history and reflects a balance between
patient observation and institution of drug therapy. The diagnosis of mild
hypertension in the office is subject to pitfalls such as "white-coat"
hypertension and pseudohypertension. For patients presenting with a
diastolic blood pressure inconsistent with the presence of end-organ
damage, ambulatory blood pressure monitoring may be of value. After a
diagnosis of mild hypertension is established, institution of drug therapy
is not an immediate issue in low-risk patients lacking end-organ damage.
Mild hypertension tends to regress over time; therefore, nonpharmacologic
measures of blood pressure reduction should be used first.
Echocardiographic assessment of left ventricular mass is a noninvasive
method to assess the severity of established cases and can guide decisions
regarding aggressiveness of drug therapy. Because patients with mild
hypertension make up a heterogeneous population, treatment goals need to be
individualized. For patients with ischemic heart disease, reductions in the
diastolic blood pressure below 85 mm Hg may produce adverse consequences.
In persons suffering from diabetes, congestive heart failure, renal
insufficiency, or showing increased left ventricular mass, the absolute
reduction in blood pressure is guided by the clinical response of the
coexisting disease. Finally, in patients with prior cerebrovascular
disease, blood pressure should be lowered to the lowest tolerable level to
achieve the maximum improvement in stroke reduction.
