Treating the patient with mild hypertension and renal insufficiency.

The Hypertension Detection and Follow-up Program (HDFP) first demonstrated that treatment of patients with mild hypertension (90 to 104 mm Hg diastolic) could reduce morbidity and mortality in coronary heart disease (CHD). Previous studies had already shown the beneficial effect of blood pressure reduction on renal disease, heart failure, and cerebrovascular disease. When uncontrolled, mild hypertension in the patient with renal disease will lead to further deterioration of renal function. To prevent this and other complications (such as atherosclerosis) of hypertension, whether primary or secondary, one should place these patients on antihypertensive therapy. However, standard stepped-care therapy with diuretic drugs and beta-blocking agents is now under reevaluation in view of the potential adverse effect of these agents on serum lipids and renal function. Beta-blocking drugs, furthermore, tend to increase peripheral resistance, a hemodynamic effect opposite to that desired in these patients. Other drugs, acting centrally or peripherally on the nervous system, also have some undesirable features in addition to troublesome side effects. Prazosin, a vasodilator and effective antihypertensive agent with a different mechanism of action, has no adverse action on lipids and renal function, lowers peripheral resistance, and does not cause many of the side effects that limit use of the other drugs. It therefore appears to be a good choice for initial therapy in mild to moderate hypertension with associated renal insufficiency.