Management of mild hypertension: Too little emphasis on metabolic factors

EDITOR, - I was disappointed that the World Health Organisation-International Society of Hypertension placed such little emphasis on the impact of metabolic factors on the management of essential hypertension.1 Insulin insensitivity accompanying hypertension is associated with established or subsequent dyslipoproteinaemia (low high density lipoprotein cholesterol concentration, hypercholesterolaemia, and hypertrigly-ceridaemia) and glucose intolerance in at least 30% of patients.2,3 These disturbances will be compounded by treatment with preparations that combine a thiazide with a β blocker, leading to an 11-fold increased incidence of diabetes over the following 10 years.4 Although the published guidelines recommend treatment with a diuretic in combination with a β blocker for mild hypertension,1 they contain no suggestion that screening for metabolic dysfunction should be routine in the work up of hypertensive patients as an aid to the selection of appropriate pharmacological treatment. Nor is the need for continued surveillance for the development of diabetes mentioned. This seems paradoxical since the paper acknowledges that “serious cardiovascular disease is also determined by . . . diabetes, dyslipidaemia, central obesity.” I suspect that I am not alone in frequently stopping treatment with a preparation combining a thiazide with a β blocker in patients recently diagnosed as diabetic who are overweight or elderly and have antecedent hypertension; this often leads to improved metabolic control. The introduction of the paper states that guidelines should provide critical and balanced information on benefits and limitations of the various therapeutic interventions. These guidelines seem …