Advertisement

Drugs

, Volume 56, Supplement 2, pp 11–21 | Cite as

Stratégies pharmaco-thérapeutiques actuelles dans le traitement de l’hypertension artérielle

  • M. Beaufils
  • D. L. Clément
Review Article

Résumé

Le but du traitement d’une hypertension artérielle est de réduire à terme la morbidité et la mortalité cardiovasculaires associées à cette affection. Ce résultat n’est que très imparfaitement atteint avec les stratégies thérapeutiques actuelles, ce qui conduit à réactualiser périodiquement les recommandations. Deux recommandations sont apparues en 1997, celle de l’Agence Nationale d’Accréditation et d’Evaluation en Santé (ANAES) et celle du Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure dans sa sixième version. L’une et l’autre préconisent le passage dans tous les cas par des mesures hygiéno-diététiques, ce qui n’est pas nouveau. La décision d’instaurer un traitement pharmacologique apparaît, dans les nouvelles recommandations, de plus en plus guidée par les facteurs associés du risque vasculaire et l’existence d’une atteinte des organes cibles. En fonction du risque associé, le traitement médicamenteux est débuté à des seuils très différents de pression artérielle.

Le traitement pharmacologique débute classiquement par une monothérapie, dont la nature est largement guidée par des profils patients, définis de manière de plus en plus précise par les recommandations. Une telle monothérapie ne permet d’obtenir un contrôle tensionnel suffisant que chez 50 à 60% des patients. En cas de non réponse, il est conseillé de changer de classe thérapeutique. En cas de réponse incomplète, la meilleure attitude est d’associer un second produit d’une classe synergique. L’usage en première intention d’une association fixe à faible dose est une stratégie alternative, encore discutée, mais dont les adeptes sont de plus en plus nombreux. Cette stratégie est maintenant admise par les grandes recommandations.

Current Pharmacotherapeutic Strategies in the Treatment of Arterial Hypertension

Abstract

The aim of the treatment of hypertensive disease is to reduce its associated cardiovascular morbidity and mortality. Simply reducing blood pressure levels is clearly not adequate since its impact on coronary heart disease is particularly unsatisfactory. Moreover, the beneficial effects of antihypertensive treatment seem to plateau for several years, and the incidence of cardiac and renal failure is even increasing. Therefore, recommendations by groups of national or international experts are periodically updated on the basis of current epidemiological data. Two such recommendations appeared in 1997, one from the Agence Nationale d’Accréditation et d’Evaluation en Santé (ANAES) in France and the other from the Joint National Committee (JNC) on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, in the United States. Both advocate the use of lifestyle modifications in all patients. The threshold blood pressure level at which pharmacological therapy is introduced largely depends on associated cardiovascular risk factors and/or involvement of target organs. The JNC recommends a particularly low threshold in patients with diabetes.

Pharmacological treatment is usually initiated with a single drug. The choice of any one drug depends on the patient profile and takes into consideration such characteristics as age and associated risk factors or comorbidity. Some represent a contraindication for certain therapeutic classes (for example, asthma for β-blockers, renovascular hypertension for ACE inhibitors), while others are a specific or even ‘compelling’ indication (heart failure, angina, renal disease, peripheral vascular disease etc.). This patient profiling is very precisely described in the new recommendations. However, any such single drug therapy provides adequate blood pressure control in no more than about 50 to 60% of patients.

When the patient does not respond to the drug used or experiences side effects, substitution of a drug from another pharmacological class is recommended. In contrast, if the patient is a responder but blood pressure remains above the target level, it is preferable to add a second drug from a class offering complementary action. The use of a combination therapy allows blood pressure control in more than 80% of patients. More authors are suggesting that combination therapy as first-line treatment may increase the number of responders and reduce the impact of counter-regulatory effects occurring with single drug therapy (e.g. sodium retention, or sympathetic activation). This alternative strategy is now acknowledged in the recommendations.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Collins R, Peto R, MacMahon S. Blood pressure, stroke, and coronary heart disease. Part 2, short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet 1990; 335: 827–38Google Scholar
  2. 2.
    Document ANDEM/Service des Références Médicales. Octobre 1997. Texte intégral accessible sur le site Internet de l’hôpital Broussais: http://www.hbroussais.fr/ANDEMHTA/ANDEM.html
  3. 3.
    The sixth report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure. Arch Int Med 1997; 157: 2413–46Google Scholar
  4. 4.
    Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998; 351: 1755–62PubMedCrossRefGoogle Scholar
  5. 5.
    Clément DL. Office versus ambulatory recordings of blood pressure (OvA): a European multicentre study. The Steering Committee. J Hypertens Suppl. 1990; 8(6): S39–41PubMedGoogle Scholar
  6. 6.
    Clément DL, Duprez D, De Buyzere M. White-coat hypertension. In: Hansson L, editor. 1993–1994, Hypertension. Annual critical reviews for the clinician. Current Sci 1994: 61–71Google Scholar
  7. 7.
    Alderman MH. Blood pressure management: individualized treatment based on absolute risk and the potential for benefit. Ann Int Med 1993; 119: 329–35PubMedGoogle Scholar
  8. 8.
    Chatellier G, Ménard J. The absolute risk as a guide to influence the treatment decision-making process in mild hypertension. J Hypertens 1997; 15: 217–9PubMedCrossRefGoogle Scholar
  9. 9.
    Krakoff LR. American Society of Hypertension Workshop on Absolute Risk. Am J Hypertens 1996; 9 (4 Pt 1): 397–9PubMedCrossRefGoogle Scholar
  10. 10.
    Freis ED. The efficacy and safety of diuretics in treating hypertension. Ann Intern Med 1995; 122: 223–6PubMedGoogle Scholar
  11. 11.
    Kaplan NM. The case for low-dose diuretic therapy. Am J Hypertens 1991; 4: 970–1PubMedGoogle Scholar
  12. 12.
    Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA 1995; 273: 1450–6Google Scholar
  13. 13.
    Lewis EJ, Hunsicker LG, Bain RP, et al. The effect of angiotensin converting enzyme inhibition on diabetic nephropathy. N Engl J Med 1993; 329: 1456–62PubMedCrossRefGoogle Scholar
  14. 14.
    Hannedouche T, Landais P, Goldfarb B, et al. Randomised controlled trial of enalapril and beta blockers in non-diabetic chronic renal failure. BMJ 1994; 309: 833–7PubMedCrossRefGoogle Scholar
  15. 15.
    Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997; 350: 757–64PubMedCrossRefGoogle Scholar
  16. 16.
    Dahlöf B, Pennert K, Hansson L. Reversal of left ventricular hypertrophy in hypertensive patients. A meta-analysis of 109 treatment studies. Am J Hypertens 1992: 5: 95–110Google Scholar
  17. 17.
    Devereux RB. Do antihypertensive drugs differ in their ability to regress left ventricular hypertrophy? Circulation 1997; 95: 1983–5PubMedCrossRefGoogle Scholar
  18. 18.
    Clément DL, De Bruyzere M, Duprez D. Antihypertensive effects of calcium antagonists. Clinical facts and modulating factors. Am J Hypertens 1994; 7: 16S–22SGoogle Scholar
  19. 19.
    Lever AF, Ramsay LE. Treatment of hypertension in the elderly. J Hypertens 1995; 13: 571–9PubMedCrossRefGoogle Scholar
  20. 20.
    Insua JT, Sacks HS, Lau TS, et al. Drug treatment of hypertension in the elderly: a meta analysis. Ann Intern Med 1994; 121: 355–62PubMedGoogle Scholar
  21. 21.
    Neaton JD, Grimm RH, Prineas RJ, et al. Treatment of mild hypertension study: final results. JAMA 1993; 270: 713–24PubMedCrossRefGoogle Scholar
  22. 22.
    Grimm RH, Flack JM, Grandits GA, et al. Long-term effects on plasma lipids of diet and drugs to treat hypertension. Treatment of Mild Hypertension Study (TOMS) Research Group. JAMA 1996; 275: 1549–56PubMedCrossRefGoogle Scholar
  23. 23.
    Grimm Jr RH, Grandits GA, Cutler JA, et al. Relationships of quality-of-life measure to long-term lifestyle and drug treatment in the Treatment of Mild Hypertension Study. Arch Int Med 1997; 157: 638–48CrossRefGoogle Scholar
  24. 24.
    Materson BJ, Reda DI, Cushman WC. Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. N Engl J Med 1993; 328: 914–21PubMedCrossRefGoogle Scholar
  25. 25.
    Materson BJ, Reda DJ, Cushman WC. Department of Veterans Affairs single-drug therapy of hypertension study. Revised figures and new data. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Am J Hypertens 1995; 8: 189–92PubMedCrossRefGoogle Scholar
  26. 26.
    Références Médicales Opposables françaises. Journal Officiel: 12 juillet, 1998Google Scholar
  27. 27.
    Stratégie dans le traitement de l’HTA essentielle. Fiches de transparence. Agence du Médicament, édition 1997Google Scholar
  28. 28.
    Epstein M, Bakris G. Newer approaches to antihypertensive therapy: use of fixed-doses combination therapy. Arch Int Med 1996; 156: 1969–78CrossRefGoogle Scholar
  29. 29.
    Reid JL. Pharmacokinetic and pharmacodynamic aspects of the choice of components of combination therapy. J Hum Hypertens 1995; 9(S4): S19–S23PubMedGoogle Scholar
  30. 30.
    Menard J. Le développement clinique d’une bithérapie antihypertensive en combinaison fixe. J Hum Hypertens 1995, 9 Suppl. 4: S11–S17PubMedGoogle Scholar

Copyright information

© Adis International Limited 1998

Authors and Affiliations

  • M. Beaufils
    • 1
  • D. L. Clément
    • 2
  1. 1.Service de Médecine InterneHôpital TenonParis Cedex 20France
  2. 2.Service de Cardiologie et AngiologieHôpital UniversitaireGentBelgique

Personalised recommendations