Pharmacologic Treatment of Uncomplicated Essential Hypertension: Renin and/or Echocardiography Guided?

To the Editor: The clinical relevance of the heterogeneity of responses to antihypertensive drug treatments and possible mechanisms were recently addressed in the article titled “Renin-Guided Treatment of Hypertension: Time for Action”.1 Therapeutic responses are not considered as random phenomenon or related to demographic features. The heterogeneity of hypertension is to be minimized by using the capacity of plasma renin activity, to predict blood pressure response to both initial and add-on drug therapy.1 This obvious benefit is definitively related and dependent on the cardiovascular system adaptation to hypertension and to the nonhomogenous neurohormonal and hemodynamic profiles of hypertensive patients.2–4 The heterogeneity of uncomplicated hypertensive patients could also be minimized by assessing the morphological adaptation of the heart to hypertension, as determined by echocardiography. When this particular characteristic is taken into consideration, distinct common denominators emerge.4 Thus, about one-third of hypertensive patients have eccentric left ventricular hypertrophy with normal systolic function and the hemodynamic profile of these patients corresponds to the volume-dependent hypertension postulated by Laragh.1,2,5 Patients with eccentric geometry have low serum renin levels.3 The remaining two-thirds, on the contrary, have normal ventricular geometry (50%), concentric remodeling (15%), or concentric hypertrophy (10%). The neurohormonal profile is one of medium to high renin serum levels (>0.65 ng/ml) with normal to high peripheral vascular resistance and cardiac output.2,3 These patients resemble the renin-mediated vasoconstrictor hypertension.1 Therefore, left ventricular geometry indirectly provides valuable information, which could help to match pharmacological treatment with the corresponding neurohormonal and hemodynamic profiles of a given hypertensive patient.4