Managing high-risk patients with hypertension: focus on the renin-angiotensin system

The goal of treating hypertension has evolved from merely lowering blood pressure to an emphasis on the more important objective of decreasing morbidity and mortality. Recent trials have emphasized, however, that the major benefit in outcome relates to the level of blood pressure achieved. Hypertension associated with other risk factors, such as age, diabetes, nephropathy, and left ventricular hypertrophy, places patients at high risk of myocardial infarction, stroke, renal failure, and cardiovascular death. In numerous studies, reductions in end points were usually achieved with combination therapy. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) reaffirmed the value of diuretics in treating high-risk hypertension and reducing morbidity, but it also confirmed the necessity of combination drug therapy. Agents that block the effects of angiotensin II are an important component of antihypertensive therapy because of their proven ability to lower the incidence of cardiovascular and renal events in high-risk hypertensive patients.