To the Editor:
The comments raised by Barrios et al are interesting and reveal the importance of treating uncontrolled arterial hypertension and refractory arterial hypertension (RAH). With respect to the population under study, 25 (14%) of the 181 patients had a history of stable ischaemic cardiopathy (in all cases the ischaemic event had taken place more than 6 months previously); 12 were in the group receiving spironolactone (14%), and 13 were receiving doxazosin (14%) (differences are not significant). This history of ischaemic cardiopathy was not included in later multiple regression analysis. Patients with a history of heart failure had been excluded from the analysis according to the "c" criterion (suffering from a systemic disease that could interfere in the evaluation of the evolving changes in arterial pressure), since the evaluation of the change in arterial pressure was the most measureable parameter in the study. It must be emphasised that, out of a potential population of 687 patients with poorly controlled RAH, we only analysed the response of 181 patients (26%) in the end.1
The results of the ONTARGET and TRANSCEND studies have been very important for clinical practice, but as Barrios et al correctly point out, not all of the patients were hypertensive and the mean value for clinical arterial pressure at the beginning of the study, before receiving telmisartan or ramipril, was 141/82 mm Hg. We will have to wait for the definitive analysis and the publication of the cardiovascular complications relating to changes in arterial pressure in order to really know how much they were decreased in these studies. It is possible that the drop in arterial pressure was very beneficial in patients with uncontrolled high arterial pressure, and that the most significant side effects presented in patients with normal or low arterial pressure, given that all of them were treated equally (controlling arterial pressure was not the primary goal in these studies).
It is evident that a randomised clinical trial is the only method for evaluating the effectiveness of 2 treatment alternatives; however, the lack of conclusive evidence and the difficulty of carrying out this type of study are well-known in the case of RAH.2 Furthermore, patients with RAH frequently suffer from side effects that oblige them to change treatments,3 which also makes such an evaluation more difficult. While we gather more evidence, reducing arterial pressure, regardless of the method that is used, will probably be the best treatment for preventing complications, for which reason evaluating data such as that in our study can be useful in clinical practice.