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Background: Increasing concern over long-term drug treatment of mild hypertension has stimulated several studies of weight reduction. Phase I of the Trial of Antihypertensive Interventions and Management demonstrated a short-term effect of weight loss on blood pressure control in overweight persons with mild hypertension, who were either taking placebo or taking low-dose monotherapy. Phase II investigates the long-term benefit of weight loss on the ability to maintain blood pressure control. Methods: From 10 148 community-based screenees, 587 persons (5.8%), aged 21 to 65 years, entered a multicenter, randomized drug (double-blind, placebo-controlled) and diet trial. Participants had a diastolic blood pressure between 90 and 100 mm Hg and were at 110% to 160% of their ideal weight. They were randomized to a usual diet (n=296) or to a weight loss diet (n=291) and within each diet group to placebo, chlorthalidone, 25 mg/d, or atenolol, 50 mg/d. Treatment failure was defined as using additional antihypertensive medications if diastolic blood pressure rose above 90 mm Hg according to protocol-specified criteria. Results: At baseline, mean diastolic blood pressure was 93 mm Hg; systolic blood pressure, 143 mm Hg; weight, 88 kg; percent ideal weight, 137%; age, 48 years; 56% were men; and 33% were black. Mean follow-up was 4.5 years. There was a net loss of 2 to 3 kg with weight loss diet compared with usual diet over most of the follow-up period. The 5-year incidence of treatment failure was 56.7 per 100 participants with usual diet and 49.8 per 100 with weight loss. Long-term weight loss decreased failure of blood pressure control for those receiving placebo or low-dose diuretic or [Beta]-blocker by 23%. The results were similar in direction in each drug group. Conclusions: The Trial of Antihypertensive interventions and Management demonstrated that weight reduction is an effective long-term therapy for maintaining blood pressure in the normal range when used as monotherapy or in combination with either thiazide diuretics or [Beta]-blockers. Consequently, weight loss should be recommended for the management of obese individuals with mild hypertension. (Arch Intern Med. 1993;153:1773-1782)

* This report examines the effect of weight loss, alone and in combination with drugs, on diastolic blood pressure change in the Trial of Antihypertensive Interventions and Management (TAIM), which is a randomized, multicenter, placebo-controlled clinical trial of drug and diet combinations in the treatment of mild hypertension among 787 patients. Diastolic blood pressure drop (11.6 mm Hg) at 6 months among those patients who were randomized to weight reduction and placebo drug treatment was greater among those who lost 4.5 kg or more, than the 7-mm Hg drop for those who lost less than 2.25 kg or for the placebo-treated control group, and it was statistically equivalent to the reduction achieved by 25 mg of chlorthalidone or 50 mg of atenolol (11.1- and 12.4-mm Hg drop, respectively). Weight loss potentiated effects of drugs, with reductions of 18.4 mm Hg, for those patients who were taking atenolol and had a 4.5-kg or more weight loss, and of 15.4 mm Hg, for those patients who were taking chlorthalidone and had at least a 2.25-kg weight loss. We concluded that effective weight loss ([Mathematical Expresssion Omitted] 4.5 kg) lowers blood pressure similarly to low-dose drug therapy and potentiates drug effects, with the apparent 4.5-kg threshold being lowered to 2.25 kg for those patients who receive chlorthalidone. (Arch Intern Med. 1992;152:131-136)

The plethora of drugs makes selection difficult. Here's help: A class-by-class assessment of antihypertensive agents that will make it easier to devise an effective, well-tolerated regimen. Advantages of thiazide diuretics [...]

Individualizing hypertension therapy Today's wealth of possibilities for treating hypertension not only creates a therapeutic challenge--it also allows a far more precise drug choice for each patient. With more than [...]

Calcium channel blockers lower blood pressure by inhibiting calcium from entering cells of the blood vessel wall, preventing the vessel from becoming constricted. Although the calcium channel blockers verapamil and nifedipine lower blood pressure, there are some limitations upon their use. Verapamil can be given intravenously but can cause heartbeat abnormalities, while nifedipine given orally can cause a rapid uncontrollable decrease in blood pressure. Nicardipine is similar to nifedipine but has properties more conducive for intravenous injection. Intravenous nicardipine was given to 73 of 123 patients enrolled in the study with severe hypertension. Pretreatment blood pressures averaged 213 over 126 mm Hg. Blood pressures were reduced to an average of 160 over 95 in 67 patients. Of the 49 patients who did not respond to placebo treatment, subsequent nicardipine therapy lowered blood pressures similarly. The most common adverse effect was headache, which was experienced by 24 percent of the patients. The drug worked equally well in patients having organ damage from high blood pressure. Intravenous nicardipine drug therapy was safe and effective in reducing severe hypertension.

Hypertension: Starting drug therapy A preponderance of evidence supports treating even mildly elevated blood pressure with drugs. But questions remain about reducing coronary risk and special situations like isolated systolic [...]

EXPRESS STOP Clues to secondary hypertension: Only 5% of hypertensive patients are thought to have secondary hypertension, but one of these potentially curable conditions is found in up to a [...]

Initial measures in hypertension Take multiple readings before labeling a patient hypertensive and initiating lifelong therapy. Nonpharmacologic measures are the first step. Use the initial evaluation to help plan drug [...]

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)