Letter by Izzo Regarding Article “How the Times Have Changed: Antihypertensive Agents”

To the Editor:

It is hard to disagree with Dr Bloch’s commentary (Bloch MJ. How the times have changed: antihypertensive agents [published online February 18, 2020]. Cardiology Consultant. https://www.consultant360.com/exclusive/cardiology/hypertension/how-times-have-changed-antihypertensive-agents). The laboratory monitoring proposed then and now has always been debatable, but the bigger issue to me remains, “What is the definition of hypertension?” More specifically, “How should blood pressure (BP) be determined and monitored?” Given the intrinsic variability of BP and the confounding caused by intrinsic BP variations such as the white coat effect, it seems clear to me that traditional office BP is simply inadequate. But how should we implement better methods, such as automated office BP, home monitoring, or 24-hour ambulatory BP monitoring?

The drugs have not changed much, but at least it has been finally acknowledged in most guidelines that combination therapy is required. Some of us realized this decades ago. But should more modern BP-measurement methods be employed before and after treating? There also remain controversies and differences among guidelines regarding treatment goals. Apparent BP control rates may have improved a little, but some very fundamental issues remain unresolved.

Joseph L. Izzo, MD
Professor and Chief of Clinical Pharmacology
Department of Medicine
Jacobs School of Medicine & Biomedical Sciences
University at Buffalo
Buffalo, NY

The Author Replies:

I thank Dr Izzo for his comments. Certainly, we still have many questions to answer, but I also think that thanks to the relentless work of physicians like Dr Izzo and his colleagues in the field of hypertension, we are finding more and more consensus about the questions he highlights. Given its variability, BP is definitely a difficult biomarker to work with, but I believe that there is increasing recognition that standard office measurements alone will not suffice for clinical decision-making. Similarly, the consensus around the importance of combination therapy, and fixed-dose combinations in particular, is actually a major step forward from where we were in the field years ago.

Michael J. Bloch, MD
Associate Professor
University of Nevada School of Medicine

Medical Director
Renown Vascular Care
Renown Institute for Heart and Vascular Health

President
Blue Spruce Medical Consultants, PLLC
Reno, Nevada