Hypertension in the young - Preventing the evolution of disease versus prevention of clinical events

Two great dilemmas in the treatment of hypertension are when to treat and how to assess the effectiveness of drug therapy in younger patients. There is very little data about the most effective treatment strategies for younger patients with high blood pressure (BP) (1,2). This is because clinical trials are predicated on showing benefits of drug therapy on "hard clinical outcomes" such as stroke, coronary heart disease, and mortality. To ensure sufficient end points over the typical duration of clinical trials, the patients studied are invariably older and at high cardiovascular risk by virtue of established complications. Indeed most trials have only recruited patients over age 50 years, and typically the mean age of patients in trials is 65 years or more. Moreover, most of these older patients with established vascular damage require multiple drug therapies to control their BP, making it difficult to isolate the potential benefit (or harm) of specific drug therapies, over and above the overwhelming benefit of BP lowering per se in these older populations.