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2 decades of hypertension
One Cardiology Today Editorial Board member discusses progress since 1997.
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Editor’s Note: Cardiology Today is celebrating its 20th anniversary in 2017. We are reaching out to experts in cardiology for their take on changes in CV medicine since the publication launched in 1997. In this issue, George L. Bakris, MD, focuses on hypertension.
Despite advances in knowledge over the past 20 years about the risks conferred by hypertension, the prevalence of hypertension continues to increase. Current estimates suggest that hypertension affected 825 million people worldwide in 2015 and will affect well over 1 billion people by 2025.
A recent paper published in JAMA showed how the global burden of hypertension has increased over time (Foroufanzar MH, et al. JAMA. 2017;doi:10.1001/jama.2016.19043; for more information, see page 8.). Worldwide, the rate of systolic BP > 140 mm Hg increased from 17,307 per 100,000 people in 1990 to 20,526 per 100,000 people in 2015; age-standardized rates showed a similar trend.
Management of hypertension was quite different 20 years ago than it is now. Back then, diuretics were first-line, and then we could add renin-angiotensin system blockers or beta-blockers or use single-pill combinations. Now, we have moved more toward combinations. Thiazide-type diuretics, such as chlorthalidone and indapamide, renin-angiotensin-aldosterone system blockers or calcium channel blockers can be first-line, while beta-blockers are now considered to be only for patients with CHD.
I personally am using much more single-pill combinations of calcium channel blockers/renin-angiotensin system blockers as initial therapy, and am more likely to use thiazide-type diuretics as the preferred diuretic.
Among the most significant advances related to hypertension in the past 20 years were outcome trials such as ACCOMPLISH comparing single-pill combinations, new insights about mineralocorticoid receptor antagonists in resistant hypertension and the advent of device therapies such as baroreflex activation therapy and renal denervation for resistant hypertension. Also of note are studies of the potassium binder patiromer (Veltassa, Relypsa), the results of which have enabled us to study the effect of mineralocorticoid receptor antagonists in patients with advanced kidney disease and hypertension.
– George L. Bakris, MD
Cardiology Today Editorial Board Member
University of Chicago Medicine
Disclosure: Bakris reports consulting for AbbVie, Bayer, Janssen, Merck and Relypsa.