As millions more patients with mild hypertension are being brought into active drug therapy, the need for effective medications that are safe for long-term use has increased. This is, in part, as a result of the adverse effect on coronary heart disease mortality observed in two of the major therapeutic trials, the Oslo Study and the Multiple Risk Factor Intervention Trial. In both of these, the diuretic-first, stepped-care approach was used. Administration of diuretics is frequently associated with such biochemical abnormalities as hypokalemia, hypercholesterolemia, and hyperglycemia. Thus, the wisdom of the routine use of a diuretic as the first choice of therapy is being questioned. Alternative drugs for initial therapy include beta blockers and selective alpha1 blockers. With beta blockers, there is a tendency for serum triglycerides to increase and high-density lipoprotein cholesterol to decline, as well as a tendency for an undesirable reduction in cardiac output and an increase in peripheral resistance. Selective alpha1 blockers, because they lower blood pressure in a hemodynamically more favorable manner and have a tendency to improve the lipid profile, are becoming increasingly attractive as initial therapy for mild hypertension and also as part of the combination needed for more severe disease. The favorable results noted with the new selective alpha1 blocker terazosin strongly support its addition to the list of preferred drugs for initial therapy.
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