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Managing hypertension effectively requires careful evaluation of the patient, in particular for the presence of target-organ damage and of other risk factors for atherosclerosis. Dietary management has proved to be unsatisfactory in most hypertensive patients, as patients resist dietary restrictions or any other changes in life-style. Drug treatment has been shown to significantly reduce morbidity and mortality in patients with diastolic blood pressures above 104 mm Hg. Evidence suggests that drug treatment is also effective in those with diastolic pressures between 90 and 104 mm Hg. Selection of drugs is still an empirical decision--treatment with an oral diuretic usually is effective for mild hypertension (diastolic pressures 90 to 115 mm Hg). A sympathetic depressant, often propranolol, may be added to the regimen next, and if this is ineffective, a vasodilator (usually hydralazine) is included. Common side effects of antihypertensive drugs are seldom serious but can be annoying. Patients should be forewarned about them, and about the effects of untreated hypertension in an effort to improve compliance.

The 1984 report of the Joint National Committee on Detection, Evaluation, and Treatment of Hypertension for the first time recommended beta blockers as an alternative to diuretics for step 1 of stepped-care treatment. Numerous studies have shown that beta blockers are as effective as diuretics for monotherapy in patients with mild hypertension. They are the only antihypertensive drugs that have been shown to be cardioprotective following a myocardial infarction. Beta blockers are especially indicated for step 1 therapy in young patients (particularly those with evidence of hyperkinetic circulation), in patients who have had a myocardial infarction, and in patients with angina, migraine, or hereditary tremor because they are helpful in treating these conditions as well as in managing hypertension. Angiotensin converting enzyme inhibitors and calcium channel blockers are challenging beta blockers and diuretics as the drugs of choice for initial therapy of hypertension in selected patients. Time will ultimately determine the relative roles of each as step 1 therapy.

The risk of stroke and myocardial infarction is increased in patients with elevated systolic blood pressure. Although treatment trials have demonstrated the benefit of antihypertensive therapy in elderly patients with diastolic hypertension, the only trial conducted in elderly patients with isolated systolic hypertension is currently in progress. A six-month trial of nonpharmacologic therapy should generally be the initial treatment in patients with isolated systolic hypertension. Then, if systolic pressure remains elevated, a cautious trial of drug treatment is reasonable. The drug used should be started in a low dose, and the dose should be titrated slowly. With this approach, antihypertensive treatment of elderly patients with isolated systolic hypertension may be well tolerated and ultimately beneficial.

The fourth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure varies from the Committee's earlier reports in a number of ways. The introduction of additional effective antihypertensive agents with varying pharmacologic properties has undoubtedly stimulated the Joint National Committee to recommend a more flexible individualized approach to treatment. Diuretics, beta-adrenergic receptor blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers are all recommended as reasonable first-step agents in treatment of hypertension. The pharmacologic properties, cost, and side-effect profiles of these drugs differ considerably, and the effectiveness of certain agents appears to vary according to the patient's age and race. All these factors should be considered, as should the existence of any concomitant disease, in choosing initial treatment. Whatever drug is chosen, the physician must continue to provide careful follow-up to ensure that adequate blood pressure control is achieved with minimal side effects.