Correspondence

Initial Treatment of Hypertension

N Engl J Med 2003; 349:1090-1091September 11, 2003

Article

To the Editor:

In her Clinical Practice article on the treatment of hypertension, Dr. August (Feb. 13 issue)1 suggests that asthma and chronic obstructive pulmonary disease (COPD) are contraindications to beta-blocker treatment. Beta-blockers are underused in the management of conditions such as angina, myocardial infarction, congestive heart failure, and hypertension. Morbidity and mortality are increased as a result. The myth that beta-blockers are contraindicated in most patients with asthma and COPD contributes to underprescribing. Data show that cardioselective beta-blockers are safe in such patients.2

Gil Porat, M.D.
Colorado Springs Health Partners, Colorado Springs, CO 80907
poratgil@hotmail.com

2 References

1. 1

   August P. Initial treatment of hypertension. N Engl J Med 2003;348:610-617
   Full Text | Web of Science | Medline

2. 2

   Salpeter SR, Ormiston TM, Salpeter EE. Cardioselective β-blockers in patients with reactive airway disease: a meta-analysis. Ann Intern Med 2002;137:715-725
   Web of Science | Medline

To the Editor:

August's advice for treating the 50-year-old patient described in the vignette appears to be based more on optimism than on realism. Lifestyle modifications, although often helpful, tend to be disappointing in the long term and usually do not solve the problem of hypertension in black patients.1 Given the facts that hypertension is more severe and target-organ damage — particularly end-stage renal disease — more prevalent among blacks and that most patients with hypertension require more than one drug for the achievement of the target blood pressure,2 the initial management for this patient should be more aggressive, such as a fixed low-dose combination therapy that includes hydrochlorothiazide and an angiotensin-converting–enzyme inhibitor.1,2

Kenrick Berend, M.D.
Diatel Curaçao, Willemstad, Netherlands Antilles
kenber@attglobal.net

2 References

1. 1

   Weir MR. Initial choices in the treatment of hypertension. In: Oparil S, Weber MA, eds. Hypertension: a companion to Brenner and Rector's The Kidney. Philadelphia: W.B. Saunders, 2000:479-91.
   

2. 2

   Gradman AH, Acevedo C. Evolving strategies for the use of combination therapy in hypertension. Curr Hypertens Rep 2002;4:343-349
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Porat makes an excellent point about the potential for underuse of beta-blockers in patients with hypertension and cardiovascular disease and coexisting asthma or COPD. He cites a recent meta-analysis of randomized, controlled trials involving single-dose or long-term treatment with cardioselective beta-blockers in patients with asthma or COPD and reversible bronchoconstriction; the analysis indicated that sustained use was not associated with a significant change from base line in the forced expiratory volume in one second and that long-term therapy did not increase respiratory symptoms.1 Nevertheless, some patients with reversible airway obstruction have a negative reaction to beta-blockers; thus, caution is still appropriate, and cardioselective beta-blockers are preferred.

Dr. Berend suggests a more aggressive initial pharmacologic strategy (fixed low-dose combination therapy) to treat the 50-year-old black patient with hypertension. Although fixed low-dose combination therapy has not been studied as extensively as the approach I recommend, it is gaining popularity because of the potential benefits of achieving target blood pressures sooner and the possibility that low-dose combination therapy will be associated with fewer adverse effects. I agree that his suggestion is reasonable, although it is not as well supported by data from large clinical trials.

Phyllis August, M.D., M.P.H.
Weill Medical College of Cornell University, New York, NY 10021
paugust@med.cornell.edu

1 References

1. 1

   Salpeter SR, Ormiston TM, Salpeter EE. Cardioselective β-blockers in patients with reactive airway disease: a meta-analysis. Ann Intern Med 2002;137:715-725
   Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Mitchell J. Barnett, Gary Milavetz, Peter J. Kaboli. (2005) β-Blocker Therapy in Veterans with Asthma or Chronic Obstructive Pulmonary Disease. Pharmacotherapy 25:11, 1550-1559
   CrossRef