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All of the major clinical trials that employed diuretics as initial monotherapy or as one of several first-step drugs have demonstrated a marked reduction in overall cardiovascular events and stroke deaths in treated patients. Benefit has been demonstrated in all trials in patients with initial diastolic pressures of 95 mm Hg or above and in the Hypertension Detection and Follow-up Program, the only study to test the hypothesis, benefit of treatment was noted in patients with pretreatment diastolic pressures of 90 to 95 mm Hg. Although several of the trials failed to show a significant decrease in coronary events in treated patients, the two studies (Hypertension Detection and Follow-up Program and European Working Party on Hypertension in the Elderly) that treated either elderly patients or patients with pretreatment target-organ involvement, reported a reduction in deaths from ischemic heart disease following effective lowering of blood pressure. The long-term benefits of effective treatment of hypertension appear to justify the use of pharmacological intervention if nondrug treatment proves ineffective.

Implications of the clinical trials on the management of hypertension.