The first edition of the ABC of Hypertension, published in 1981, rose out of a series of review articles published in the British Medical Journal under the titles of ABC of blood pressure measurement and ABC of blood pressure reduction.
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Since that time there have been a great many advances in our understanding of clinical aspects of hypertension that have necessitated regular updating. In particular there have been major improvements in the measurement of blood pressure with increasing awareness of the relative importance of 24 hour ambulatory blood pressure monitoring versus casual office blood pressure readings. In addition, the focus of the management of hypertensive patients has moved to encompass a measure of total cardiovascular risk rather than just the blood pressure. This has been helped by the ready availability of simple risk charts, particularly those published by the British Hypertension Society and the joint British Societies. Along with this there has been an increasing awareness that the height for systolic blood pressure is a better predictor of cardiovascular risk than the diastolic blood pressure and that isolated systolic hypertension, with its high risk, is well worth treating. Even today, however, many clinicians who were originally taught that the diastolic pressure was more important than the systolic are finding this radical change in emphasis to be somewhat startling.
The first edition of the ABC of Hypertension was published before the era of angiotensin converting enzyme inhibitors. There is no doubt that these agents, together with the more recently synthesised angiotensin receptor blockers are by far the most tolerable antihypertensive drugs. They have transformed the treatment of diabetic hypertensives and hypertensives with concomitant heart disease or nephropathy. Since the publication of the fourth edition of the ABC of Hypertension, we have seen publication of the Losartan Intervention For Endpoint (LIFE) study and the Anglo Scandinavian Cardiac Outcomes Trial (ASCOT). In both of these trials the drugs that block the renin-angiotensin system were found to be superior to previous standard regimes of atenolol with or without a thiazide diuretic. These two trials have heralded the end of the supremacy of blockers in the treatment of uncomplicated hypertension. Again, this will be a radical turnaround for those clinicians who have put their faith in blockers for uncomplicated essential hypertension in the hope that they might be better at preventing first coronary events than other agents. Thus, since 1980 we have become better at assessing our patients’ blood pressure, better at assessing their cardiovascular risk, and we have more effective and more tolerable antihypertensive agents. In previous years a clinician, when faced with a patient where the value of treatment was open to question, might have taken the view “when in doubt, don’t treat.” Nowadays the same clinician, when faced with a similar patient, is more likely to say “when in doubt, treat.” This view, together with the arrival of the statins, means that lives are being saved and people are living longer.
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