VOL. III NO. IV JULY/AUGUST 2001 THE JOURNAL OF CLINICAL HYPERTENSION 207

THE IMPORTANCE OF SYSTOLIC BLOOD PRESSURERecent evidence from the National Health and Nu-trition Examination Surveys (NHANES), as well asfrom the Framingham Heart Studies, indicates thatsystolic blood pressure is a better determinant ofcardiovascular risk than diastolic blood pressure.

In this issue of the JCH, Whyte and colleaguesreach several conclusions based on a reanalysis ofthe NHANES data. Not only is systolic bloodpressure more important than diastolic in deter-mining risk; they note that classification of variousstages of blood pressure on the basis of systolicblood pressure alone would be more accurate thanif diastolic pressure were used. This review also is-sues a challenge. In most clinical trials, as well asin surveys of blood pressure control in the UnitedStates, diastolic blood pressure is controlled in a high percentage of patients—more than75%–80% in most cases. In contrast, systolicblood pressure control at the goal level of <140mm Hg is achieved in fewer than 60%, even incarefully controlled studies. The authors make astrong case for paying more attention to systolicblood pressure elevation.

ALPHA BLOCKERS AND PROSTATE DISEASE In another paper on drug therapy of hypertensivepatients, Martell and colleagues describe the re-sults of treatment in a group of hypertensive indi-viduals with benign prostatic hypertrophy.Patients who were on one antihypertensive drugand whose blood pressures remained elevatedwere given the α blocker doxazosin in increasingdosages. Various parameters were employed to

analyze the effects of this agent on prostatic symp-toms as well as prostate function. The authorsconcluded that the α blocker, when added toother drug therapy, not only improved symptomsof prostatism but also lowered blood pressure still further.

Recent data, however, indicate that α-blockertherapy probably is not preferred in the initial man-agement of hypertension. Reductions in morbidityand mortality are greater when a diuretic is used.The Sixth Joint National Committee (JNC) did notrecommend α blockers as initial treatment, and thishas been reaffirmed by the results of newer trials;these agents are not suggested as first-line therapy.However, in patients with prostate disease who are already receiving antihypertensive drugs, the addi-tion of an α blocker may lower blood pressure stillfurther and improve symptoms of prostate disease.

BETA BLOCKERS—STILL INDICATED IN HYPERTENSION TREATMENT?Dr. Hanes and her group discuss the benefits andpossible problems with the use of β blockers in themanagement of hypertension and other cardiovas-cular conditions. Although recent papers havestressed potential problems with the use of theseagents and the fact that, in the elderly, diureticsmay be more effective in reducing coronary arterydisease events, the authors correctly conclude thatthere is a place for β blockers in the managementof hypertension.

In both the young and the elderly, β blockers re-duce the occurrence of strokes and congestive heartfailure. The data on elderly patients suggest thatthey are less effective in coronary heart disease.

E d i t o r i a l

Systolic Hypertension; αα Blockers and Prostatism; Are ββ Blockers Still Indicated; Diabetes, Obesity, and Hypertension—Comments on the JCH Contents

Marvin Moser, MDEditor in Chief

THE JOURNAL OF CLINICAL HYPERTENSION VOL. III NO. IV JULY/AUGUST 2001208

However, as noted by Hanes, these conclusions arebased on trials with a high dropout rate and largenumbers of crossovers to other medications. Thereis some concern about the increase in triglyceridelevels and lowering of HDL levels in patients whoare treated with β blockers. These effects and effectson insulin resistance may not, however, be of clini-cal importance, based on the results of newer trialsin which a β blocker-based regimen has been com-pared to other antihypertensive therapy in diabeticsand other patients. A significant reduction in allcardiovascular events was noted in the β blocker-based treatment groups. Hanes and her colleagueshighlight the fact that in addition to their potentialbenefits in the treatment of hypertension, β blockershave been found to be beneficial in the managementof congestive heart failure, the post-myocardial in-farction patient, and various arrhythmias. Theyconcur with the recommendation of the JNC that βblockers alone, or in combination with a diuretic,are among the preferred choices for the manage-ment of hypertension.

OBESITYDr. Pickering, in an interesting column, focuses onthe growing evidence of obesity in this countryand explores some reasons why adolescents andyounger people are becoming more obese. He citeseating habits and less exercise as the probablemajor causes and offers suggestions for physiciansto become more active in obesity control.

DIABETES, RENAL DISEASE, ANDHYPERTENSIONFinally, Drs. Weber and Weir discuss an importantdisease entity. Diabetes is increasing rapidly, bothin the U.S. and worldwide. It is clearly related tothe occurrence of obesity and the metabolic syn-drome, which includes abdominal obesity, hyper-triglyceridemia, low HDL levels, and hypertension.

Whereas diabetologists have, for many years,focused on the management of glycemia with nu-tritional intervention and careful glucose monitor-ing, it has been shown in recent clinical trials thatmore effort must be invested in correcting otherabnormalities—specifically, hypertension and hy-perlipidemia—in the diabetic population. Resultsindicate that cardiovascular morbidity and mortal-ity, both related to diabetes, might be more dra-matically affected by lowering blood pressure, forexample, than by achieving glycemic control.

Drs. Weber and Weir review results of treat-ment of high-risk diabetic hypertensives from threenew trials. Results demonstrate that progressionfrom less severe to more severe renal disease, aswell as progression from established to end-stagerenal disease, transplantation, or death, can be re-tarded with a treatment regimen that includes anangiotensin II receptor blocker (ARB), relative to atreatment program that does not include an ARB,an ACE inhibitor, or a calcium channel blocker.

These trials build on previous evidence thatagents that block the renin-angiotensin system(usually in combination with a diuretic) are help-ful, in diabetics both with and without protein-uria, in preventing or slowing the progression ofrenal disease.

These observations, plus recent data from otherclinical trials, should lead to a change in recom-mendations for initial therapy. It is reasonable toassume that ACE inhibitors, usually combinedwith a diuretic, should now be included as initialtherapy in hypertension management and thatARBs (again, usually with a diuretic) should nowbe recommended as one of the preferred therapiesin the management of patients with diabetes, withor without proteinuria.

It is obvious that more attention must be paidto treating hypertension, the metabolic syndrome,diabetes and obesity.