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What is the best way to manage hypertension?

Marina Virko
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Patients suffering from high blood pressure may be able to get much better results by changing their drug therapy than by increasing the dose. Based on these results of their study, in the scientific journal JAMA, the Swedish doctors are calling for looking more closely at personalized therapy strategies in the future. However, a German expert doubts that such approaches can currently be introduced into clinical practice.

High blood pressure: the disease of the century

Hypertension is a widespread condition worldwide. A 2021 study by the World Health Organization (WHO) showed that from 1990 to 2019, the number of people suffering from the disease had doubled, reaching nearly 1.3 billion in the 200 countries involved in the analysis. In Germany alone, they number between 20 and 30 million, according to the German Hypertension League.

If left untreated, hypertension can lead to kidney complications, heart disease and strokes.

Although various effective medications are now available, only 25 percent of women and 20 percent of men affected by the condition are able to meet the aspired treatment goals, according to a WHO study.

Changing medications instead of increasing their dosages

Scientists at Uppsala University have studied the reasons for this phenomenon. In particular, a team led by cardiologist Johan Sundström investigated how the effectiveness of various hypertension drugs differed from person to person. Researchers examined 280 volunteers to see if there was an optimal blood pressure medication for each individual patient, trying to find out if there was a potential for personalized management of high blood pressure.

To do this, test subjects took four common drugs of different classes in sequence over a year -- thiazide diuretics, ACE inhibitors, angiotensin II antagonists, and calcium antagonists. Their influence varied greatly from person to person, and in some patients, a certain substance worked better to lower blood pressure than another one. Also, for many subjects, changing the medication had a greater effect than doubling the dose of the current one.

Are the guidelines outdated?

The authors say these findings challenge the treatment guidelines valid in many countries, which recommend the four well-studied groups of drugs equally to all hypertensive patients. In their point of view, this study provides evidence that commonly used antihypertensive substances vary in efficacy depending on the individual, opening the door to personalized therapy as a means to improve blood pressure reduction.

In a press release, Sundström specifies: "If we tailor a drug to each individual, we can achieve greater effect than if we randomly select one medication from these four groups."

Markus van der Giet, a hypertensiologist at the Charité Hospital in Berlin, believes that such a personalized approach to treatment would be desirable, but is unlikely to be feasible in practice at present.

He states: "It would mean that patients would have to try all medications one by one, which does not work in daily clinical practice and would probably frustrate patients."

Nevertheless, the study shows that some drugs may be more helpful for some patients than for others.

However, van der Giet, who is also president of the German Hypertension League, stresses, that it is impossible to predict the reaction to a particular medicine.

Adapting therapy to patient groups

In fact, the authors themselves acknowledge that individualized therapy would require further research into the biomarkers to make such predictions possible.

"However, such biomarkers are not as stable as one might think, and they can change depending on blood sampling conditions, because of daily fluctuations and changes of temperature," van der Giet notes.

An expert suspects, that it would make more sense to customize therapies to particular groups of people. Since we know, for example, that certain groups - whether women or men, elderly or young people - respond differently to medications. For example, calcium antagonists or diuretics will work well in older patients whose blood vessels are losing elasticity. Beta-blockers, on the other hand, are likely to be better in younger people, van der Giet says.

"This personalization, involving larger clusters rather than an individual, can be very helpful."


  1. Heterogeneity in Blood Pressure Response to 4 Antihypertensive Drugs. A Randomized Clinical Trial. Johan Sundström, MD, PhD1,2; Lars Lind, MD, PhD1; Shamim Nowrouzi, MD1; et alEmil Hagström, MD, PhD1; Claes Held, MD, PhD1; Per Lytsy, MD, PhD1; Bruce Neal, MD, PhD2; Kerstin Marttala, RN1; Ollie Östlund, PhD3. JAMA. 2023;329(14):1160-1169. doi:10.1001/jama.2023.3322

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