Each year in the United Kingdom alone there are 20 000 preventable deaths from cardiovascular disease attributable to hypertension. Much of the excess mortality and associated morbidity arises from poor control of blood pressure among people known to have hypertension. For the past two years in the United Kingdom, general practitioners have had the prime responsibility for tackling this problem, along with financial incentives to meet targets for detecting and controlling high blood pressure. Yet, despite many clinical trials and guidelines, they may be unsure about which antihypertensive drug to use first and how to combine treatments.

In 2004 the National Institute for Health and Clinical Excellence (NICE) recommended thiazide or thiazide-like diuretics as the first line treatment for most patients, with the addition of β blockers as the next step.^w1This echoed the advice given in the US Joint National Committee's guidelines the previous year.^w2Near simultaneous guidance from the British Hypertension Society, however, recommended for the first time drugs acting on the renin-angiotensin system—angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers—as first line treatment for “younger, non-black”patients.^w3In effect, the resulting confusion endorsed earlier European guidelines which advocated leaving the choice of drug to individual practitioners.^w4

An eclectic approach to prescribing …