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. 2001 Jul;86(1):113–120. doi: 10.1136/heart.86.1.113

Matching the right drug to the right patient in essential hypertension

M Brown 1
PMCID: PMC1729796  PMID: 11410577

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Figure 1:  .

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Absolute versus relative risk of myocardial infarction and stroke. Data from MacMahon et al2 and Collins et al3 are used to illustrate how myocardial infarction (MI) appears a more common complication of hypertension than stroke (cerebrovascular accident, CVA), because its incidence starts higher in the normal part of the blood pressure distribution. However, stroke has a higher relative risk (plotted as 40% v 25% for each 10 mm Hg increase in systolic blood pressure), and overtakes myocardial infarction as an absolute risk in severe hypertension.

Figure 2:  .

Figure 2:  

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Blood pressure indications for treatment (British Hypertension Society guidelines). Reproduced from Ramsay et al,4 with permission of BMJ Publishing Group.

Figure 3:  .

Figure 3:  

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NA or Na in hypertension? The principal initiating factors in hypertension are noradrenaline (NA) released from sympathetic nerves, which causes vasoconstriction, or sodium (Na+) which increases blood volume. Since blood pressure = peripheral resistance × cardiac output, hypertension cannot occur until vasoconstriction by noradrenaline and its stimulation of renin secretion fails to be offset by pressure natriuresis. Apart from the key players of NA, Na+, renin and angiotensin, there are a very large number of molecules involved in the synthesis, secretion or response to these, which provide candidate genes to explain inherited susceptibility to hypertension. The figure illustrates just three of these, relevant to the cell signalling of aldosterone. ENaC, epithelial sodium channel; SGK, serum glucocorticoid kinase.

Figure 4:  .

Figure 4:  

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Drugs acting on the renin-angiotensin-aldosterone system. Drugs which suppress the system are shown in red, those which activate the system are in green. ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCBs, calcium channel blockers.

Figure 5:  .

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AB/CD schema for optimisation of antihypertensive treatment. In choosing initial treatment—step 1—age in a white population is used as a surrogate for plasma renin, which falls with age. The typical younger patient (aged < 55 years) responds better to ACE inhibition or β blockade, whereas in the older patient (aged > 55 years) calcium channel blockade or diuretic is the preferred starting treatment; angiotensin receptor blockade can substitute for ACE inhibition in intolerant patients. Because the response of patients to the two drugs within each pair is well correlated, there is usually no point in switching an unresponsive patient to the other of the pair (for example, A to B); therefore step 2 in such a patient is to switch to one of the other pair. If the blood pressure is still above target, step 3 is to combine one drug from each pair.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

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