Despite advances in hypertension treatment, blood pressure control rates remain low in the general population.1 The Quality and Outcome Framework (QoF) for GPs have two indications for hypertension. These are:
The percentage of patients with hypertension in whom the last blood pressure reading (measured in the preceding nine months) is 150/90mmHg or less. 10 points
The percentage of patients aged 79 or under with hypertension in whom the last blood pressure reading (measured in the preceding nine months) is 140/90mmHg or less. 50 points.
There are a number of lifestyle modifications that can help modify blood pressure and these include: weight reduction, dietary sodium restriction, physical activity and moderate consumption of alcohol but most patients will require pharmaceutical intervention.
In five large double-blind, placebo-controlled studies, more than one agent was required to achieve desired target BP goals. In the Hypertension Optimal Treatment (HOT) study, for example, 68% of subjects required more than one agent. 41% of subjects were taking felodipine plus an ACE inhibitor, and 28% were taking felodipine plus a beta blocker.2
In the United Kingdom Prospective Diabetes Study (UKPDS), 29% of subjects required three or more agents to achieve a BP of <150/85mmHg at nine years after randomisation.3
Given the poor BP control rates observed worldwide, it is important to carefully examine the numerous factors influencing BP control. One important factor influencing BP control is the efficacy of the antihypertensive agent being prescribed. It is important to choose an effective first-line agent in order to maximise the chances of achieving a target BP.
The tolerability profile of an agent can have a major impact on BP control. Since hypertension is generally asymptomatic for most patients, a poorly tolerated drug that has common and possibly troublesome adverse effects may cause the patient to feel worse while taking the drug than prior to initiating therapy.
This may lead to patient discontinuation of treatment, which, in turn, leads to poor BP control. Convenience of dosing can also have an important influence on patient compliance and thus on BP control. Compliance tends to be highest with once-daily dosing of a drug that may be taken with or without food. An antihypertensive agent should therefore not only be effective, but should also have an excellent safety and tolerability profile, as well as a simple convenient dosing schedule.
According to widely accepted guidelines, different classes of antihypertensive agents may be used as first-line treatment for hypertension, including diuretics, ß-adrenergic blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, and calcium antagonists.
These agents reduce blood pressure by various mechanisms. They are therefore more or less effective, depending on the prevailing pathogenic factors in a given hypertensive patient. When necessary, different types of antihypertensive agents may be combined.

1. Erdine S. ESH Scientific Newsletter 2011
2. Kjeldsen SE, et al. Hypertension. 1998; 31: 1014–20
3. UK Prospective Diabetes Study (UKPDS). Group Lancet 1999; 354(9178): 602.