Intended for healthcare professionals

Clinical Review Evidence based management of hypertension

What are the elements of good treatment for hypertension?

BMJ 2001; 322 doi: (Published 05 May 2001) Cite this as: BMJ 2001;322:1107
  1. Cynthia D Mulrow, professor of medicinea,
  2. Michael Pignone (, assistant professor of medicineb
  1. a Division of General Internal Medicine, University of Texas at San Antonio, San Antonio, TX 78249, USA
  2. b University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
  1. Correspondence to: M Pignone

    This is the third in a series of five articles

    This paper summarises the drugs available for treating patients with hypertension. It is based on a book chapter for which more than 1500 trials and systematic reviews were screened. The book chapter covers dyslipidaemia, diabetes, tobacco misuse, physical inactivity, antiplatelet treatment, alcohol consumption, and vitamin supplementation in patients with hypertension.1

    Summary points

    For the initial treatment for hypertension a single agent may be appropriate or, depending on the patient's risk factors, a combination of two or more may be needed

    Treatment decreases risks of fatal and non-fatal stroke, cardiac events, and death and may improve quality of life

    Thiazide diuretics seem the best first line agents for reducing rates of stroke and death

    Angiotensin converting enzyme inhibitors, some β blockers, and some long acting calcium channel blockers are efficacious alternatives

    Short acting α antagonists should be avoided as first line agents

    Short acting calcium channel blockers should be avoided

    Benefits and harms of antihypertensive drug treatment

    General benefits

    Many large randomised placebo controlled trials consistently show that antihypertensive drug treatment decreases the risk of fatal and non-fatal stroke, cardiac events, and death in men and women with systolic or diastolic hypertension,13 without adverse effect on quality of life, which may even be improved.4 People at greater cardiovascular risk when they start treatment, such as elderly patients with other relevant risk factors, derive the most absolute benefit from drug treatment.

    Specific antihypertensive drugs as first line agents

    It is not clear whether the benefits of specific antihypertensive drugs come from their direct effects on raised blood pressure or whether they act by various other multiple indirect actions. It is difficult to assess effects of particular agents, because most large trials have used a stepped care approach in which a second or third drug is added when the first choice does not reduce blood pressure …

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