Hypertension: The Good, the Bad, and the Unknown

For this issue's focus on hypertension, we have assembled a small portfolio of articles describing recent provocative advances in the study of hypertension.

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But first, the bad news. Hypertension impacts roughly 30 percent of the adult U.S. population and the majority of Americans aged 65 or older, based on NHANES surveys. The prevalence will continue to rise rapidly as the U.S. population continues to get older. Moreover, although there have been improvements over the past 10 years, less than 50 percent of patients under treatment for hypertension reach target for blood pressure control. A similar level of poor control is seen in hypertensive patients with chronic kidney disease (CKD), where hypertension is known to promote progression of kidney damage. Laura Svetkey and Crystal Tyson address the prevalence of hypertension in CKD, treatment goals, and the debates underlying choices in pharmacologic and nonpharmacologic therapies. In her piece, Jane Reckelhoff describes the potential risks of treating men and women with the same interventions based on her studies identifying gender-specific mechanisms underlying the pathogenesis of hypertension.

Among the obstacles to improving outcomes in patients with hypertension is the lack of new therapies. One could argue that there has not been a truly novel drug for hypertension since the development of ACE inhibitors in the 1980s, considering that angiotensin receptor blockers and renin inhibitors also target the renin-angiotensin system. In another article in our series, Svetkey and Tyson detail potentially good news regarding progress in developing a novel approach for hypertension treatment: renal nerve ablation. If ongoing prospective randomized controlled trials confirm the efficacy of this nonpharmacologic intervention, we would have a new tool for patients with resistant hypertension consisting of a single intervention with apparent long-lasting effects circumventing the need for daily medication dosing.

And now for the unknown. Jens Titze explains new concepts of sodium homeostasis whereby macrophages can regulate non-osmotic sodium storage in the skin to influence blood pressure responses to increased dietary salt intake. Finally, Steven Crowley summarizes the growing literature that supports a role for the immune system to regulate blood pressure and target organ damage in hypertension through effects on the vasculature and the kidney. This work raises the possibility of targeting inflammatory pathways in the treatment of hypertension and its complications.

Together, the articles in this series highlight opportunities to turn the bad news about hypertension into good news for our patients.