Alternatives to traditional first-line antihypertensive treatment: unresolved questions and therapeutic dilemmas. A personal approach.

The best antihypertensive regimen for use in patients with mild-to-moderate hypertension has not been determined. When nonpharmacological treatment of hypertension fails, initial drug treatment with diuretic drugs, sympatholytic agents (including beta-adrenergic receptor blockers), or vasodilators will result in satisfactory blood pressure control. However, each of these therapies has effects that are independent of their antihypertensive activity and that should be considered before a selection is made for initial therapy. The adverse effects of diuretic agents and beta-adrenergic receptor-blocking drugs on plasma lipid profiles may diminish the beneficial effects of blood pressure reduction. On the other hand, the hypocholesterolemic effect of alpha-adrenergic receptor antagonists, the potential cardioprotective effect of angiotensin converting enzyme inhibitors, and the salutary effects of calcium channel blockers on left ventricular function are responses that would support the use of vasodilatory therapy. Vasodilating antihypertensive drugs may be more beneficial than "standard" therapy and should be considered for the initial treatment of newly diagnosed hypertensive patients.