New controversies in hypertension: questions answered, answers questioned.

Despite multiple, interdisciplinary group recommendations, we are still on uncertain ground when it comes to treatment of most aspects of hypertension. Seven major areas of controversy include mild hypertension, the relevance of hypertension and lipids, hypertensive agents and electrolyte imbalance, treatment and regression of left ventricular hypertrophy, isolated systolic hypertension, ambulatory blood pressure monitoring and overtreatment of hypertension--the "j shaped curve." Although our knowledge of these aspects has advanced tremendously, significant doubts exist as to our present approach. Key publications are reviewed to evaluate our present knowledge and recommendations are made. The 1988 recommendations of the Joint National Committee on Detection, Evaluation and Treatment of Hypertension both answered and raised some questions regarding treatment of high blood pressure. We lack information on the treatment outcomes and many of us remain unconvinced that our present approach is the best we can do. Many other questions abound. Should the treatment of mild hypertension be as aggressive as it is at present or should systolic hypertension in the elderly be treated at all? There are striking variations and recommendations of other groups outside the United States which reaffirm our lack of evidence. Ideally, we ought to be able to reduce or abolish the recognized poor outcomes of treated hypertension: heart attack, heart failure, stroke, renal failure and retinopathy. Adequate control of blood pressure has gone a long way towards preventing stroke, accelerated hypertension and hypertensive encephalopathy. Congestive heart failure has also been reduced. There is a singular lack of evidence of the influence on either total mortality or morbidity from coronary events.(ABSTRACT TRUNCATED AT 250 WORDS)