A re-examination of stepped-care: A retrospective and a prospective

Alberto Zanchetti

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Diuretics have so far enjoyed a prominent position in all stepped-care programs, as the preferred first choice drug in most American schemes or as an alternative first choice drug with respect to beta-blockers in the WHO scheme. Among various reasons for this prominence has been that antihypertensive drugs available until recently all gradually led to sodium and water retention, and therefore required to be combined with a diuretic. This is no longer true: several antihypertensive agents are available now that do not require combination with diuretics, these new agents including not only beta-blockers but also angiotensin-converting enzyme (ACE) inhibitors and calcium entry blockers. Furthermore, some concern about the metabolic effects of diuretics has recently been raised, especially because of the failure to prevent coronary heart disease by the current diuretic-based antihypertensive regimens. Without denying the importance that diuretics have had in the past in making antihypertensive therapy successful and their continuing essential role in treating severe hypertension, it is likely in my opinion, that in future years diuretics are going to be more often used as agents of second choice, mostly in combination with beta-blockers, ACE inhibitors, and perhaps, some of the calcium blockers. In conclusion although opinions of various experts about the sequence of choices between antihypertensive drugs may obviously differ, there is no doubt that the addition of new classes of effective agents, such as the ACE inhibitors and the calcium entry blockers, is making antihypertensive therapy more flexible and more easily suitable to the needs of individual patients.

Original languageEnglish
Pages (from-to)S126-S131
JournalJournal of Cardiovascular Pharmacology
Issue number1
Publication statusPublished - 1985


  • Angiotensin-converting enzyme
  • Beta-blockers
  • Calcium blockers
  • Diuretics
  • Stepped-care

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Pharmacology


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