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. 2007 Jul 5;26(Suppl 2):3–6. doi: 10.1002/clc.4960261403

Getting to goal in complex patients

C Venkata 1, S Ram 1,✉
PMCID: PMC6654412  PMID: 12622319

Abstract

Traditionally, the term complex hypertension has been applied to patients who have clinical evidence of target organ damage. However, this definition can be expanded to include many hypertensive patients who either present without manifest disease but harbor silent concomitant organ damage, or belong to a high‐risk group and are likely to develop such damage. Thus, the number of patients who deserve special consideration as complex patients is considerable. Various factors may contribute toward classifying a patient as having complex hypertension. These include severe hypertension; concomitant conditions such as diabetes, chronic renal insufficiency, coronary artery disease, or congestive heart failure; and high‐risk populations such as the elderly and African Americans. Recent evidence demonstrates that aggressive goal blood pressure (BP)‐lowering therapy is the key toward halting the progression of vascular disease. Although the choice of initial therapy seems less important than achieving goal B P, the drug selected must impart efficacy, organ protection, and tolerability. Combination therapy consisting of calcium‐channel blockers and angiotensin‐converting enzyme inhibitors seems to achieve these desirable effects. Several clinical trials have demonstrated these agents to have favorable effects on BP and organ protection even in complex hypertension, particularly when used in combination.

Keywords: complex hypertension; calcium antagonists; combination therapy; uncontrolled hypertension; goal blood pressure, and; treat‐to‐goal target

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References

  • 1. Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, Menard J, Rahn KH, Wedel H, Westerling S: Effects of intensive blood‐pressure lowering and low‐dose aspirin in patients with hypertension: Principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998; 351: 1755–1762 [DOI] [PubMed] [Google Scholar]
  • 2. UK Prospective Diabetes Study Group . Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. Br Med J 1998; 317: 703–713 [PMC free article] [PubMed] [Google Scholar]
  • 3. Zhang ZH, Francis J, Weiss RM, Felder RB. The renin‐angiotensin‐aldosterone system excites hypothalamic paraventricular nucleus neurons in heart failure. Am J Physiol Heart Circ Physiol 2002; 283: H423–H433 [DOI] [PubMed] [Google Scholar]
  • 4. Kurpesa M, Trzos E, Drozdz J, Bednarkiewicz Z, Krzeminska‐Pakula M: Myocardial ischemia and autonomic activity in dippers and non‐dippers with coronary artery disease: Assessment of normotensive and hypertensive patients. Int J Cardiol 2002; 83: 133–142 [DOI] [PubMed] [Google Scholar]
  • 5. Pepine CJ: Potential role of angiotensin‐converting enzyme inhibition in myocardial ischemia and current clinical trials (abstr). Clin Cardiol 1997; 20 (suppl II): II‐58–II‐64 [PubMed] [Google Scholar]
  • 6. Wenzel RR, Bruck H, Noll G, Schafers RF, Daul AE, Philipp T: Antihypertensive drugs and the sympathetic nervous system (abstr). J Cardiovasc Pharmacol 2000; 35: S43–S52 [DOI] [PubMed] [Google Scholar]
  • 7. Ram CV: Antihypertensive drugs: An overview. Am J Cardiovasc Drugs 2002; 2: 77–89 [DOI] [PubMed] [Google Scholar]
  • 8. Gradman AH, Cutler NR, Davis PJ, Robbins JA, Weiss RJ, Wood BC, Michelson EL: Long‐term efficacy, tolerability, and safety of the combination of enalapril and felodipine ER in the treatment of hypertension. Enalapril‐Felodipine ER Factorial Study Group. Clin Ther 1998; 20: 527–538 [DOI] [PubMed] [Google Scholar]
  • 9. Scholze J, Zilles P, Compagnone D: Verapamil SR and trandolapril combination therapy in hypertension—a clinical trial of factorial design. German Hypertension Study Group. Br J Clin Pharmacol 1998; 45: 491–495 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10. Karlberg BE, Lins LE, Hermansson K: Efficacy and safety of telmisartan, a selective AT1 receptor antagonist, compared with enalapril in elderly patients with primary hypertension. TEES Study Group. J Hypertens 1999; 17: 293–302 [DOI] [PubMed] [Google Scholar]
  • 11. Fenves A, Ram CV: Are angiotensin‐converting enzyme inhibitors and angiotensin‐receptor blockers becoming the treatment of choice in African‐Americans? (abstr). Curr Hypertens Rep 2002; 4: 286–289 [DOI] [PubMed] [Google Scholar]
  • 12. Sareli P, Radevski IV, Valtchanova ZP, Libhaber E, Candy GP, Hond ED, Libhaber C, Skudicky D, Wang JG, Staessen JA: Efficacy of different drug classes used to initiate antihypertensive treatment in black subjects: Results of a randomized trial in Johannesburg, South Africa. Arch Intern Med 2001; 161: 965–971 [DOI] [PubMed] [Google Scholar]
  • 13. Skoularigis J, Eitzman L, Davis J, Strugo V, Sareli P: Nifedipine versus captopril in the management of moderate hypertension in black patients. Am J Hypertens 1994; 7: 440–447 [DOI] [PubMed] [Google Scholar]
  • 14. Materson BJ, Reda DJ, Cushman WC, Massie BM, Freis ED, Kochar MS, Hamburger RJ, Fye C, Lakshman R, Gottdiener J. Single‐drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. N Engl J Med 1993; 328: 914–921 [DOI] [PubMed] [Google Scholar]
  • 15. Materson BJ, Reda DJ, Cushman WC: Department of Veterans Affairs single‐drug therapy of hypertension study. Revised figures and new data. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Am J Hypertens 1995; 8: 189–192 [DOI] [PubMed] [Google Scholar]
  • 16. Franklin SS, Larson MG, Khan SA, Wong ND, Leip EP, Kannel WB, Levy D: Does the relation of blood pressure to coronary heart disease risk change with aging? The Framingham Heart Study. Circulation 2001; 103: 1245–1249 [DOI] [PubMed] [Google Scholar]
  • 17. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (also available at: www.ama‐assn.org/internal). Arch Intern Med 1997; 157: 2413–2446 [DOI] [PubMed] [Google Scholar]
  • 18. Bakris GL, Williams M, Dworkin L, Elliott WJ, Epstein M, Toto R, Tuttle K, Douglas J, Hsueh W, Sowers J: Preserving renal function in adults with hypertension and diabetes: A consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis 2000; 36: 646–661 [DOI] [PubMed] [Google Scholar]
  • 19. Chaturvedi N, Sjolie AK, Stephenson JM, Abrahamian H, Keipes M, Castellarin A, Rogulja‐Pepeonik Z, Fuller JH: Effect of lisinopril on progression of retinopathy in normotensive people with type 1 diabetes. The EUCLID Study Group. EURODIAB Controlled Trial of Lisinopril in Insulin‐Dependent Diabetes Mellitus. Lancet 1998; 351: 28–31 [DOI] [PubMed] [Google Scholar]
  • 20. Reja A, Tesfaye S, Harris ND, Ward JD: Is ACE inhibition with lisinopril helpful in diabetic neuropathy? (abstr). Diabet Med 1995; 12: 307–309 [DOI] [PubMed] [Google Scholar]
  • 21. Velussi M, Brocco E, Frigato F, Zolli M, Muollo B, Maioli M, Carraro A, Tonolo G, Fresu P, Cernigoi AM, Fioretto P, Nosadini R: Effects of cilazapril and amlodipine on kidney function in hypertensive NIDDM patients. Diabetes 1996; 45: 216–222 [DOI] [PubMed] [Google Scholar]
  • 22. Shigihara T, Sato A, Hayashi K, Saruta T: Effect of combination therapy of angiotensin‐converting enzyme inhibitor plus calcium‐channel blocker on urinary albumin excretion in hypertensive microalbuminuric patients with type II diabetes. Hypertens Res 2000; 23: 219–226 [DOI] [PubMed] [Google Scholar]
  • 23. Herlitz H, Harris K, Risler T, Boner G, Bernheim J, Chanard J, Aurell M: The effects of an ACE inhibitor and a calcium antagonist on the progression of renal disease: The Nephros Study. Nephrol Dial Transplant 2001; 16: 2158–2165 [DOI] [PubMed] [Google Scholar]
  • 24. Wright JT Jr, Kusek JW, Toto RD, Lee JY, Agodoa LY, Kirk KA, Randall OS, Glassock R: Design and baseline characteristics of participants in the African American Study of Kidney Disease and Hypertension (AASK) Pilot Study. Control Clin Trials 1996; 17: 3S–16S [DOI] [PubMed] [Google Scholar]
  • 25. Agodoa LY, Appel L, Bakris GL, Beck G, Bourgoignie J, Briggs JP, Charleston J, Cheek D, Cleveland W, Douglas JG, Douglas M, Dowie D, Faulkner M, Gabriel A, Gassman J, Greene T, Hall Y, Hebert L, Hiremath L, Jamerson K, Johnson CJ, Kopple J, Kusek J, Lash J, Lea J, Lewis JB, Lipkowitz M, Massry S, Middleton J, Miller ER III, Norris K, O'Connor D, Ojo A, Phillips RA, Pogue V, Rahman M, Randall OS, Rostand S, Schulman G, Smith W, Thornley‐Brown D, Tisher CC, Toto RD, Wright JT Jr, Xu S: Effect of ramipril vs. amlodipine on renal outcomes in hypertensive nephrosclerosis: A randomized controlled trial. J Am Med Assoc 2001; 285: 2719–2728 [DOI] [PubMed] [Google Scholar]
  • 26. Schrier RW, Estacio RO, Esler A, Mehler P: Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int 2002; 61: 1086–1097 [DOI] [PubMed] [Google Scholar]
  • 27. Estacio RO, Jeffers BW, Hiatt WR, Biggerstaff SL, Gifford N, Schrier RW: The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non‐insulin‐dependent diabetes and hypertension. N Engl J Med 1998; 338: 645–652 [DOI] [PubMed] [Google Scholar]
  • 28. Franklin SS, Jacobs MJ, Wong ND, L'Italien GJ, Lapuerta P: Predominance of isolated systolic hypertension among middle‐aged and elderly US hypertensives: Analysis based on National Health and Nutrition Examination Survey (NHANES) III. Hypertension 2001; 37: 869–874 [DOI] [PubMed] [Google Scholar]

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