The number of well-controlled hypertensives is unacceptably low worldwide. Respecting the circadian variation of blood pressure, nontraditional
antihypertensives, and treatment in early stages of
hypertension are potential ways to improve
hypertension therapy. First, prominent variations in circadian rhythm are characteristic for blood pressure. The revolutionary MAPEC (Ambulatory Blood Pressure Monitoring and Cardiovascular Events) study, in 3000 adult hypertensives investigates, whether
chronotherapy influences the cardiovascular prognosis beyond blood pressure reduction per se. Second,
melatonin,
statins and
aliskiren are hopeful drugs for
hypertension treatment.
Melatonin, through its scavenging and
antioxidant effects, preservation of NO availability,
sympatholytic effect or specific
melatonin receptor activation exerts
antihypertensive and anti-remodeling effects and may be useful especially in patients with nondipping nighttime blood pressure pattern or with nocturnal
hypertension and in hypertensives with
left ventricular hypertrophy (LVH). Owing to its multifunctional physiological actions, this
indolamine may offer cardiovascular protection far beyond its hemodynamic benefit.
Statins exert several pleiotropic effects through inhibition of small
guanosine triphosphate-
binding proteins such as Ras and Rho. Remarkably,
statins reduce blood pressure in hypertensive patients and more importantly they attenuate LVH. Addition of
statins should be considered for high-risk hypertensives, for hypertensives with LVH, and possibly for high-risk prehypertensive patients. The
direct renin inhibitor,
aliskiren, inhibits catalytic activity of
renin molecules in circulation and in the kidney, thus lowering
angiotensin II levels. Furthermore,
aliskiren by modifying the
prorenin conformation may prevent
prorenin activation. At present,
aliskiren should be considered in hypertensive patients not sufficiently controlled or intolerant to other inhibitors of renin-angiotensin system. Third, TROPHY (Trial of Preventing
Hypertension) is the first pharmacological intervention for prehypertensive patients revealing that treatment with
angiotensin II type 1 receptor blocker attenuates
hypertension development and thus decreases the risk of cardiovascular events.