Treatment of mild hypertension. Decision before drugs.

The treatment of mild hypertension by the primary-care physician requires an understanding of its natural history and reflects a balance between patient observation and institution of drug therapy. The diagnosis of mild hypertension in the office is subject to pitfalls such as "white-coat" hypertension and pseudohypertension. For patients presenting with a diastolic blood pressure inconsistent with the presence of end-organ damage, ambulatory blood pressure monitoring may be of value. After a diagnosis of mild hypertension is established, institution of drug therapy is not an immediate issue in low-risk patients lacking end-organ damage. Mild hypertension tends to regress over time; therefore, nonpharmacologic measures of blood pressure reduction should be used first. Echocardiographic assessment of left ventricular mass is a noninvasive method to assess the severity of established cases and can guide decisions regarding aggressiveness of drug therapy. Because patients with mild hypertension make up a heterogeneous population, treatment goals need to be individualized. For patients with ischemic heart disease, reductions in the diastolic blood pressure below 85 mm Hg may produce adverse consequences. In persons suffering from diabetes, congestive heart failure, renal insufficiency, or showing increased left ventricular mass, the absolute reduction in blood pressure is guided by the clinical response of the coexisting disease. Finally, in patients with prior cerebrovascular disease, blood pressure should be lowered to the lowest tolerable level to achieve the maximum improvement in stroke reduction.