Hypertension research into the new millennium

In the European hypertension research arena, the new millennium started with the 2000 ESH meeting in Göteborg (1). In 2010 in Oslo, we will be able to sum up where a decade of European hypertension research has taken us since the beginning of the millennium.

The breakthroughs in cardiovascular medicine over the past 50 years have been remarkable and have contributed to saving more lives of at-risk individuals than in any previous era of civilization (2).

Research in hypertension during the last century was characterized mainly by large randomized controlled trials targeting blood pressure (BP) reduction as a goal and cardiovascular mortal and morbid events as outcome. Such trials provided one important message, the better the BP control, the better the outcome. Other major research issues addressed were: At which BP should therapy be initiated? What is the BP goal for therapy? Should thresholds and targets for antihypertensive treatment differ for low vs. high risk patients? Further, we came to important conclusions as to whether systolic or diastolic BP or both should serve as the targets for treatments (3).

Despite our understanding of hypertension management, risk-factors and disease mechanisms, and despite the introduction of a large number of effective antihypertensive treatments, only a fraction of hypertensive patients achieve and remain at optimal BP levels and thus attain optimal cardiovascular risk reduction (3). Clearly from a general as well as a medical professional perspective, this cannot be seen as providing an acceptable service to the hypertensive population. Although more aggressive detection, treatment and follow-up measures have been implemented and effective combination treatments have been instituted, these strategies have provided only marginal improvements in the routine clinical management of patients.

The past three decades have witnessed a significant increase in the availability of drugs to treat hypertension (4). Large long-term randomized controlled trials have evaluated and compared the morbidity and mortality outcomes of diuretics, betablockers, calcium antagonists, ACE inhibitors and AT1 antagonists. To some extent the newer drugs may provide advantages over older agents, particularly in special patient categories (4). Our classical response to medical uncertainties has been to perform a classical outcome trial.

Although the long term future of hypertension management is not clear to us, increasing our understanding of the mechanisms and causes of the disease may provide breakthroughs that will improve management. Genetics/genomics has to prove whether or not it can provide the quantum leap to the point where it offers effective mechanistic treatments that are better than current empirical management strategies. Gene therapy still remains far away from a global and public health perspective.

We have not yet found a simple solution to the multi-factorial problem of hypertension management facing most societies globally. This is an issue that needs a dedicated and multifaceted approach that includes involvement of health professionals, government agencies, NGOs, educational institutions and health economists. The cardiovascular health sector must receive much more public attention and be considered a priority sector in all societies, rich and poor, developed and emerging.

However, hypertension and cardiovascular medicine have become victims of their own success. Progress during the last century provided us with knowledge and treatments to conquer overt disease. Since then, our goals have become fuzzier, and our collective aims more vague. How do we protect the public and the individual patient from hypertension and its complications in a society characterized by competition for scarce resources? With the rising environmental stress of global industrialization and urbanization, the prevalence of hypertension, coronary artery disease and diabetes and their complications is becoming an ever-increasing problem to most societies. Added to this is the growing global problem of physical inactivity, obesity and tobacco usage which has further increased the burden of cardiovascular disease worldwide.

Affluent western societies have benefited the most from the technological and medical revolution during the final decades of the last century, whereas for the vast majority in developing countries, even basic medical services are difficult to obtain. Medicine for people in the developing world could create benefits through well-documented, simple and affordable therapies (5,6).

An important issue for this millennium is the new global perspective of hypertension risks and the prevalence of cardiovascular disease (7). Hypertension remains one of the leading causes of death and disability in developing countries. The growing burden of hypertension in the developing world is attributed to several factors, such as urbanization, lifestyle changes and increased life expectancy, all of which are indicators of economic progress. The increasing prevalence of hypertension thus reflects the general sociopolitical and cultural transition these countries are currently facing. From the predominantly western focus that dominated the past century, hypertension and its risks are now firmly embedded in a global perspective.

The need for political incentives is increasingly discussed when considering implementation of hypertension management guidelines on a global scale. From a public health perspective, it is a great challenge to promote healthy lifestyles and behavior among all the segments of populations in all the countries around the world. There is a need for effective measures to increase awareness about hypertension, its risk factors, risk behaviors and outcomes. Management of hypertension needs to be firmly integrated into the health policy agendas at national levels.

During the 2010 ESH meeting in Oslo, June 18 – 21 (8), the future global perspective and outreach of hypertension detection, treatment and follow-up is high on the agenda. The mechanisms and management of hypertension will be discussed in a global setting, amongst a broader group of attendees than ever before, ranging from the medical profession and other health professionals to government representatives at local and national levels.

If the message on a global perspective is strongly and effectively communicated, it may have the potential to reduce the development, as well as to reduce the consequences, of hypertension and its complications globally. That would certainly be a good outcome at the very beginning of the new millennium from what is expected to be the largest hypertension meeting in the world.