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Patients with mild high blood pressure (hypertension) often have no symptoms (asymptomatic). As many antihypertensive drugs have recognized side effects, a common perception among physicians is that patients regard the treatment as worse than the disease. In recent years, studies of drugs and their side effects have included evaluations of effects on quality of life. A recent study, the Trial of Antihypertensive Interventions and Management (TAIM), was designed to assess the effects of various combinations of drug and diet therapies on blood pressure, cardiovascular risks and quality of life after six months of therapy. The drugs studied were chlorthalidone, atenolol, and a placebo; the diets were a usual diet, a low sodium, high potassium diet, and a weight-reducing regimen. Among the quality of life issues studied were sleep, depression, anxiety, fatigue, satisfaction with physical health, and sexual satisfaction. While there may have been some clinically relevant side effects, there were no statistically significant adverse effects attributed to either antihypertensive drug or the placebo. One exception was chlorthalidone, which caused problems with erection, orgasm, and sexual interest in men who maintained their usual diets. However, the patients on chlorthalidone and a weight-reducing diet had the least sexual dysfunction, as well as the greatest weight loss and blood pressure reduction. The weight-reducing diet seemed to enhance satisfaction with physical health, while the low sodium, low potassium diet caused sexual problems in men, and had more adverse effects on sleep and fatigue than did a usual diet. The weight-reducing diet enhanced the blood pressure reducing effect of both drugs, and reduced cardiovascular risks; the combinations of low sodium, low potassium diet and antihypertensive drug therapy did not. Thus, this study suggests that a weight-reducing diet can be a useful addition to drug therapy, as it seems to prevent problems with sexual function in asymptomatic male patients with mild hypertension. (Consumer Summary produced by Reliance Medical Information, Inc.)

Drugs used to treat hypertension, abnormally high blood pressure, may actually increase the risk of developing cardiovascular disease, which affects the major blood vessels supplying the heart. Adverse effects of antihypertensive agents on cardiovascular risk factors may be particularly important in patients with less severe hypertension, because most deaths due to hypertension occur among people with moderate hypertension. The effects of diet and drug therapy for mild hypertension on cardiovascular risk factors were assessed in 692 patients with mild hypertension and whose weight was between 110 and 160 percent of ideal. Nine different therapy regimens were developed using combinations of the usual, low sodium-high potassium weight loss diets and the antihypertensive agents, chlorthalidone and atenolol, or else a placebo or substance with no known therapeutic effect. The cardiovascular risk associated with each of the nine different treatment combinations was evaluated after a period of six months. A decrease in blood pressure was associated with a reduction in cardiovascular risk in all treatment groups except that in which the usual diet was combined with chlorthalidone, which produced increased cholesterol levels. Antihypertensive agents combined with a weight loss diet were associated with the lowest risk of cardiovascular disease. The findings show that diet and antihypertensive agents have different effects on cardiovascular risk, and dietary therapy, particularly weight reduction, helped to reduce cardiovascular risk. (Consumer Summary produced by Reliance Medical Information, Inc.)

• We retrospectively analyzed two studies to determine whether smoking affected the treatment of hypertension. In a study of the effects of propranolol hydrochloride (a hepatically metabolized β-blocker) vs hydrochlorothiazide, 108 smokers and 232 nonsmokers were randomized to the propranolol treatment group. The propranolol-treated smokers tended to be younger, taller, thinner, and were more likely to be black. This group also had an initial blood pressure reduction (± SD) of -7.9 ± 12.9/ -8.7 ± 8.4 mm Hg compared with -10.7 ± 13.0/ -10.9 ± 7.1 mm Hg for the nonsmokers. Blood pressure increased less during the one-year maintenance period for the nonsmokers. However, when analyzed by race, this effect was seen in blacks, but not in whites. Diastolic blood pressure tended to be reduced more in nonsmokers (vs smokers) receiving hydrochlorothiazide (-12.1 ± 6.7 vs -10.7 ± 6.7 mm Hg, respectively). The second study compared the effects of nadolol (a renally excreted β-blocker) with bendroflumethiazide. There were no significant effects on blood pressure for either of these drugs. In both studies, there was a greater tendency for smokers to be terminated from the study irrespective of drug group. We conclude that cigarette smoking does interfere with the treatment of hypertension in general, and especially with reduction of blood pressure by propranolol in black patients.(Arch Intern Med 1988;148:2116-2119)

This study asks whether prolonged antihypertensive therapy will "cure" a substantial percent of rigorously treated hypertensive patients and whether nutritional change will add an antihypertensive effect and reduce the relapse rate. Of 584 eligible patients normotensive while receiving therapy, 496 were randomized into control and discontinued-medication groups with and without dietary intervention. At 56 weeks, 50% of those who were no longer receiving medication remained normotensive by study criteria. Randomization either to weight-loss group (mean loss of 4.5 kg [10 lb]) or to sodium-restriction group (mean reduction of 40 mEq/day) increased the likelihood of remaining without drug therapy, with an adjusted odds ratio of 2.17 for the sodium group and 3.43 for the weight group. Highest success rates were in the nonoverweight mild hypertensives with sodium restriction (78%) and the overweight mild hypertensives who were reducing their weight (72%). These data demonstrate that weight loss or sodium restriction, in hypertensives controlled for five years, more than doubles success in withdrawal of drug therapy.(JAMA 1985;253:657-664)

Are newer types of antihypertensive agents, which are currently more costly to purchase on average, as good or better than diuretics in reducing coronary heart disease incidence and progression? Will lowering LDL cholesterol in moderately hypercholesterolemic older individuals reduce the incidence of cardiovascular disease and total mortality?

The Hypertension Detection and Follow-up Program (HDFP) previously described a significant reduction in five-year, all-cause mortality in its intensively treated stepped care (SC) group relative to its referred care (RC) control group. At the time this finding was described, a proportion of the SC cohort had been treated for periods as long as 6.7 years, but comparable RC and SC mortality data beyond five years were not available. These data, which are described herein, indicate that the 6.7-year life-table mortality rates were 95.1/1000 participants for SC vs 116.3/1000 participants for RC, a larger mortality difference than was observed at five years. This favorable finding for SC extended to all major subgroups, including white women and those aged 30 to 49 years at trial entry. Six months after the close of the treatment trial, a two-year posttrial surveillance study, which extended mortality follow-up to 8.3 years, was conducted. The posttrial use of antihypertensive medication declined in SC and increased in RC participants so that by the end of the posttrial period, there was little difference in the percentages of SC and RC participants taking medication. Control of blood pressure, indicated by mean diastolic blood pressure and by percent of participants with a pressure of 90 mm Hg or less, was slightly better for SC than for RC participants (SC group, 86.5 mm Hg and 68% controlled; RC group, 87.8 mm Hg and 62% controlled). The absolute mortality advantage found at 6.7 years persisted and increased throughout the posttrial period of follow-up despite discontinuation of the formal SC therapy program. It is postulated that regression of hypertensive end-organ changes brought about by the more effective SC treatment caused this favorable outcome.(JAMA 1988;259:2113-2122)

CARE will determine whether 5 years of cholesterol-lowering therapy reduces recurrent coronary disease events in 4,159 patients who have had an AMI. The mean total cholesterol and LDL-C levels in CARE (209 and 139 mg/dl) are similar to the average levels for the US population. The results of CARE will have relevance to the treatment of the majority of patients with coronary disease who have average rather than elevated cholesterol levels.

In Reply.—Dr Finnerty asked a very cogent question: "Why wait for five years to discontinue therapy?" By implication, Dr Finnerty is asking about mild hypertensive people who are well controlled on one medication alone. We would agree with the figures he gives for those with well-controlled hypertension with mean diastolic blood pressures of 83 mm Hg. However, we interpret Dr Finnerty's data as being the experience of patients who were treated for 12 months, not six months. Also, some of our patients relapsed long after six months without medication, emphasizing the need for continued surveillance of the patient.We agree with Dr Finnerty that there are strong indications that regression of the hypertensive process may occur with prolonged therapy. We think that the period of treatment needed is probably longer than six months, but less than five years. Also, there are indications that dietary change helps blood pressure control.