Summary:Left ventricular function was studied by Mmode echocardiography at rest and during a mental arithmetic stress test and a cold-pressor test in 14 patients with mild hypertension and in 14 matched normotensive subjects. The elevation of blood pressure at rest in the hypertensive group (154+4/87+3 vs. 120+3/66+3 mmHg in the control group) was due mainly to a higher cardiac output (6.030.3 vs. 5.0+0.3 L/min), which was related to elevations of stroke volume and heart rate (73+2 vs. 66 + 2 beatdmin). Venous plasma catecholamines were similar in the two groups. Mental stress induced cardiac output-dependent increases in blood pressure in both groups; systemic vascular resistence tended to decrease. The relative increases in diastolic and mean arterial blood pressure were smaller in the hypertensive group (IS vs. 26% and 15 vs. 21 %, respectively), which exhibited signs of a reduced cardiac compliance, possibly related to a left ventricular hypertrophy. Mental stress elevated venous plasma adrenaline similarly in the two groups; effects on noradrenaline were small. The cold-pressor test increased blood pressure similarly in the two groups, largely due to increased systemic vascular resistence; plasma noradrenaline responses were also similar. Mental stress appears to elicit a differentiated sympathetic nerve acti- vation pattern resembling the hypothalamic defense reaction. Mild hypertension seems to be associated with increased arousal and cardiac activation at rest. However, an attenuated blood pressure reactivity to mental stress may reflect reduced stroke volume responsiveness, which is related to structural changes, as heart rate reactivity tended to be enhanced in mild hypertension.

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Over the last decade the role of diuretics as first-line agents for the treatment of hypertension has diminished substantially. The present review encourages the reader to reconsider the current trend for a decline in the use of these inexpensive antihypertensive drugs whose efficacy is well documented. Diuretics have been used in 16 placebo controlled studies with over 13,000 patients as first-line drugs to lower blood pressure. These drugs were shown to reduce total mortality by 11%, cerebrovascular events by 34% and coronary morbidity by 29%. The magnitude of blood pressure reduction with low-dose thiazide diuretics is comparable to that of a therapy with high-dose thiazides, without the serious metabolic side effects observed with the higher dosage. In combination with other antihypertensive agents, diuretics counteract the compensatory regulatory responses, such as volume expansion and edema formation. Moreover, it has been shown that a combination with low-dose thiazides may not only further decrease blood pressure but also reduce cerebrovascular and coronary mortality. Advantages of diuretics in the treatment of hypertension can be appreciated in special clinical conditions, for instance in patients with edema, heart failure, renal failure, nephrotic syndrome and portal hypertension. Low-dose diuretics still have a place as first-line drugs for the treatment of mild, uncomplicated essential hypertension. Moreover, as opposed to other blood pressure lowering agents, there is sufficient scientific evidence for the primary preventive effect of low-dose thiazide.