Book Review

Individualized Therapy of Hypertension

N Engl J Med 1995; 333:396-397August 10, 1995

Article

Individualized Therapy of Hypertension
(Fundamental and Clinical Cardiology. Vol. 22.) Edited by Norman M. Kaplan and C. Venkata S. Ram. 282 pp. New York, Marcel Dekker, 1994. $99.75. ISBN: 0-8247-9262-9

In preparation for reviewing this book, I spent more than a few moments considering how much has changed in the treatment of hypertension over a generation of medical practice. For example, in my nonscientific poll of current internal-medicine residents I discovered that they find it preferable to care for a patient with hypertension rather than one with almost any other outpatient condition. These young physicians learning about the clinical aspects of hypertension consider it “easy.” They have a long list of effective, safe medications to choose from, with newer agents continually appearing. They also have very little appreciation of the strokes, congestive heart failure, and renal failure that killed tens of thousands of Americans with uncontrolled hypertension in the not too distant past.

The treatments for hypertension have traversed a wide spectrum over the past 30 years. Early pharmacologic therapy consisted of diuretics, sympatholytic agents (e.g., reserpine and methyldopa), vasodilators (e.g., hydralazine), and ganglionic blocking agents. With a limited armamentarium to treat an otherwise lethal disease, physicians prescribed an agent — usually a diuretic first, followed in stepwise fashion by the others — and hoped for the best. Patients who had side effects of medication (which were very frequent and at times incapacitating) were given a pat on the back, with a consoling comment such as, “But your blood pressure is just great.” Today we have nothing short of “designer drugs,” which in some cases block specific subtypes of receptors for specific vasoactive substances. How does one fit this into a rational approach to treating a problem that affects 25 percent of the U.S. adult population?

An outgrowth of our better understanding of hypertension as a disease syndrome rather than merely a phenotype (aided in part by research conducted with the burgeoning number of distinct classes of antihypertensive medication) is the realization that some drugs are better suited to certain patients than others. Kaplan and Ram have been strong advocates of this concept. In this book they have assembled a group of experts well versed in the clinical aspects of hypertension, who describe the pathophysiology and treatment of subgroups of the hypertensive population. The discussion is divided according to conventional but clinically relevant categories, such as hypertension in patients with diabetes, cardiac disease, renal disease, or cerebrovascular disease and those with particular demographic characteristics, such as elderly and black patients. As with many multiauthored books, the coverage of each topic is heterogeneous. In some chapters the authors merely catalogue the effects of each major class of drugs in the population of interest (for example, hypertension in the elderly). In other chapters there is a more detailed description of pathophysiology and the effects of treatment (as in the case of hypertension with cardiac and renal disease). An interesting and thought-provoking chapter deals with the important issue of improving patient compliance.

Some topics are notably absent or get very limited attention in this work. The discussion of hypertension in the elderly ignores the important issue of isolated systolic hypertension. Whether it exists or not, the concept of a J-curve relation between hypertension and coronary disease (i.e., excessive lowering of blood pressure increases coronary events) receives very brief mention in the chapter on the general management of hypertension. Only later does it resurface in the discussion of hypertension and renal disease. Also, although the chapter devoted to hypertension and endocrine disease is well written and attempts to include discussion of diseases causing secondary forms of hypertension — pheochromocytoma, hyperaldosteronism, and so on — there is no attention here or elsewhere to the evaluation and treatment of renovascular disease. There is very limited discussion of the appropriate evaluation of the individual patient who presents with hypertension or of how to evaluate patients with refractory hypertension.

Individualized Therapy of Hypertension succeeds in its mission to shine new light on the concept of different drugs for different people with hypertension. Most clinicians in training would benefit from reading such a book to help them realize that the drug that is newest (and most expensive) is not necessarily best for a given situation. Although my prescribing practices may not be affected by reading it, I suggest that those who are learning the art of treating hypertension spend some time with such a book. They will learn from the experts what works and why, rather than prescribe medications based on their perceptions and the latest pharmaceutical marketing information.

Paul R. Conlin, M.D.
Brigham and Women's Hospital, Boston, MA 02115