Blood Pressure Variability and Its Implications for Antihypertensive Therapy

Abstract

Although it is clear that antihypertensive treatment is beneficial in reducing stroke morbidity and mortality, the results of the major outcome studies show less impact on coronary heart disease. Studies utilizing 24-h blood pressure (BP) monitoring show a positive association between target organ damage and the level of 24-h BP, and with variability in BP, which is an independent determinant of target organ damage. Current understanding of the pathogenesis and pathophysiology of coronary heart disease suggests that optimal antihypertensive treatment should ensure the following: effective 24-h BP control, smooth antihypertensive effect with reduced variability; attenuation of the early morning surge in BP; maintenance of the normal circadian pattern of BP; effective therapeutic coverage in the face of suboptimal compliance; and lack of reflex activation of the sympathetic nervous system. On the basis of our current understanding, this optimum is most likely to be achieved by the use of antihypertensive agents with a long duration of action.

A multicenter, open-label study of the efficacy and safety of telmisartan in mild to moderate hypertensive patients

“…The ideal antihypertensive agent must have the following profile: it must promote effective blood pressure (BP) reduction, maintain blood pressure control over 24 hours with a single daily dose, be as effective as possible for a great number of hypertensive patients, cause no undesirable side effects have no negative effects on metabolic parameters 1 , and finally be reasonably affordable. None of the antihypertensive agents currently available have all of these characteristics.…”

“…A new class of antihypertensive agents, the angiotensin II (AII) antagonist receptors (AIIAR) (ie, losartan, valsartan, irbesartan, candesartan, and telmisartan), blocks the binding of AII to its subclass receptor AT 1 . This action prevents the potent vasoconstriction generated by AII.…”

Importance of trough : peak ratios in treatment of blood pressure in post-myocardial infarction and heart failure settings

“…It is important to note from this Figure that the change in T : P ratio occurs over the recdrug has a relatively modest T : P ratio, the consequences of this may well be a failure to control BP ommended therapeutic dosage range for the treatment of hypertension, such that the lowest dose at the end of the dosage interval and, assuming morning dosing, this would result in a failure to which might be recommended for initiation of treatment will have a sub-optimal T : P ratio, whereas the blunt the early morning BP 'surge', which is often associated with a peak in cardiovascular events. 4 higher maintenance dose of 20 mg will have an acceptable T : P ratio. This creates a practical problem for the prescribing physician, in that the lowest…”

“…4 In essence, this is most likely to be achieved using drugs that offer long duration of action. A large number of antihypertensive agents have been licensed for once daily administration and on that basis, it might be assumed that all offered this desirable characteristic, of smooth, consistent and sustained BP control.…”

“…A previous history of hypertension results in a poorer prognosis in Established epidemiological data has been utilised patients with acute MI with one-third of such to suggest an optimal approach to BP control. 4 This patients dying and one-quarter developing reinfarchypothesis is based upon the following obsertion during the first year after the onset of acute MI. 2 vations: In addition, a long-term follow-up survival study of…”