Treating high-risk hypertensive patients

Successful treatment of hypertension entails not only normalizing high blood pressure, but also addressing the associated risk factors that increase the likelihood of cardiovascular morbidity and mortality. Hypertension often occurs in a setting of insulin resistance, hyperinsulinemia, dyslipidemia, and a prothrombotic state. A number of epidemiologic studies have shown that the clustering of these abnormalities is associated with increased risk of cardiovascular morbidity and mortality. Therefore, it is rational to direct therapy at moderating these risk factors as well as at lowering blood pressure in hypertensive patients. This is particularly important in patients with comorbidities such as diabetes, cardiovascular disease, or renal insufficiency. Many physicians prescribe only diuretics and β-blockers, agents that have demonstrated efficacy in long-term randomized controlled trials. However, this approach does not consider the potential benefits of newer agents for which long-term outcome data are not yet available. The ongoing Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial, in which the angiotensin II subtype 1 receptor blocker valsartan is compared with the third-generation calcium channel blocker amlodipine, should provide important evidence on the long-term efficacy of these newer agents. A unique feature of VALUE is that it is specifically enrolling into the only current trial, now under way, hypertensive men and women at a relatively high risk for a cardiovascular event to determine the benefits of complete blockade of angiotensin II beyond those of the control of blood pressure.