BHS GUIDELINES - 2006 ON TREATMENT OF HYPERTENSION

DR. A. JABIR MD, DM, Cardiologist, Lisie Hospital, Ernakulam

Hypertension is the most common preventable case of cardiac death. About 25% of the world adult population are hypertensives. 60% of those 60 years is hypertensives. European society of hypertension classifies hypertension as follows.
Systolic Diastolic Optional <120 <80, Normal 120-129 80-85, High Normal 130 139, 85-89
Stage i Hypertension 140-159 90-99, Stage ii 160-179 100-109, Stage iii >180 >110, Isolated Systematic Hypertension >140 >90
The treatment of hypertension should be never based on a Single Value. The diagnosis should be confirmed with repeated measurements over weeks. Hypertension should be treated with life style modification and Pharmacological therapy to reduce Cardio vascular death, Myocardial infarction, Stroke, Cardiac failure and even Dementia. Treatment should be started early if the BP> 180/100, in the presence of target Organ damage, Diabetes mellitus, Renal failure and cardio vascular disease. The ultimate goal of BP control is reduction of total cardiovascular disease. Many patients require two or more drugs to control hypertension. The major first line agents in hypertension include beta blockers, calcium channel blockers, ACE inhibiters, Angiotension receptors blockers, Diuretics and Alpha blockers. Betablockers and diuretics have been considered as the first line agents by JNCV11. Now we have data available which question the role of Atenolol as the initial
hypertensive agent. This data is basically from the Meta analysis published in Lancet and the ASCOT BPLA trial. The meta analysis looked in to the outcome of treatment of hypertension treated with Atenolol compared with placebo and also with other anti hypertensive agents. In the placebo controlled trials Atenolol did not improve the outcome when compared to placebo despite good BP control. When compared to other drugs cardiovascular mortality and stroke rate was higher in
the Atenolol treated group. Other drugs were better than atenolol in improving the outcomes. ASCOT BPLA is a recently concluded randomized controlled trial involving a fairly large number of patients. Patients were randomized to two treatment groups. One group received initially amlodipine and perindopril was added if BP not controlled with amlodipine alone. The other group received Atenolol initially and thiazide was added if was not adequately controlled with atenolol monotherapy. The total mortality was higher in atenolol group. New onset diabetes was more in those who received atenolol and thiazide group. There are some more data about calcium channel blockers from trial like VALUE and CAMELOT. Amlodipine offers excellent BP control with outcome similar to Valsartan in VALUE trial. Amlodipine even produced regression of atherosclerosclerosis in the CAMELOT trial. Cardio protection offered by calcium channel blockers was better than Valsartan in the Value trial. Losartan has to be found better than atenolol in LVH regression, stroke prevention and cardio protection in the LIFE trial. So the data from the recent trials in treatment of hypertension revealed - a) Atenolol is an inferior drug regarding the outcome in the treatment hypertension.
b) New onset diabetes is much more in those who are treated with atenolol. Thiazide if given along with atenolol further increases the incidence of diabetes mellitus.
c) Atenolol is very poor in stroke protection. d) Calcium channel Blockers offers good stroke protection and cardiovascular protection. e) ARBS are good in stroke protection and LVH regression. Based on the above data British Hypertension Society has modified its 2004 guidelines. Those above the age of 55 years should be started on calcium channel blocker or diuretic as the first lien agent. Calcium channel blocker may be added to ACEl or ARB if BP not controlled with monotherapy. In CCB or diuretic group ACEI /ARB should be added to control the BP if adequate BP control is not achieved with monotherapy. Beta-blocker or alpha blocker may be added if a fourth agent is required. Atenolol is not a preferred initial agent for treatment of hypertension. It is not the control of BP alone that is important. Total cardiovascular protection is the final aim. So the associated risk factors should be optimally managed.