- Hypertension treatment, as we've already discussed, requires complex decisions about high blood pressure therapy but nevertheless there are some controversies and some particular nuances of hypertension treatment. Could you discuss controversies in hypertension treatment? The controversy is mainly what should be the target of blood pressure [in hypertension treatment], and especially in the elderly? Which drug should be the first drug of choice in treatment of hypertension? How deep you have to evaluate the patient for secondary causes of hypertension? Whether you need to do a genetic consultation in hypertension, etc. I mean, there are controversies, but today they are less controversial. We still have a controversy about optimal blood pressure target - whether it should be 130/80 or 140/90? When to define someone as hypertensive? And whether to use the beta-blocker or not use the beta blocker. Whether to start with ACE inhibitor or not? Not too many hypertension therapy controversies but we have some. If we move to pharmacological therapy of hypertension. Treatment of hypertension is quite complex, it often requires a combination of medications. There is a broad concept of "old drugs" for hypertension, then there are "new drugs", also used in combination. There are some reviews in the literature and you co-authored one of the reviews, which discusses relative merits, and pros and cons of new hypertension drug combinations vs. old hypertension drug combinations.  Dr. Ehud Grossman. Yes, in the last few years, unfortunately, in the last 5-6 years we don't have new drugs [to treat hypertension] The "new drugs" now are also "old drugs" [for hypertension treatment] In the past we used more beta-blockers and the diuretics. Thеsе were the basic cornerstones of hypertension treatment. and then we had the ACE inhibitors and Angiotensin receptor blockers [ARBs] and calcium channel blockers. Now we know that the combination of ACE inhibitor or Angiotensin receptor blocker with the calcium channel blocker is the best combination to get to targeted blood pressure, and also to prevent end organ damage and events [heart attacks and strokes]. Dr. Ehud Grossman. Then the third drug is the diuretic that we add to the combination [of hypertension treatment drugs] Beta blocker was one of the lead drugs in the past [to treat high blood pressure] Beta-blockers are now less popular, and we know today that beta-blockers protect less cardiovascular system, we don't know exactly why, but these are the facts. Beta-blockers are less efficient, especially in the elderly. That's why we keep the beta blocker for certain cases or when there is an indication to give a beta blocker - like post-myocardial infarction and tachyarrhythmia. Of course, in the elderly beta-blockers would carry more potential side effects. Yes, more side effects and less benefit. So in the elderly, definitely, we would go for diuretic, ACE inhibitor and calcium channel blockers. Among diuretics there are also some relatively new drugs like indapamide... Yes, and it's amazing, because most of the positive studies with diuretics were done with chlorthalidone.  Dr. Ehud Grossman. But in practice now you mostly use Hydrochlorothiazide, and some studies with hydrochlorothiazide failed, which means hydrochlorothiazide was less beneficial than the calcium antagonist.  Dr. Ehud Grossman. There is another drug in Israel, indapamide, and there is data about the benefit of indapamide, especially in the elderly. So I prefer today to use a fixed dose combination of ACE inhibitor or angiotensin receptor blocker and calcium antagonist [to treat hypertension]. If the patient does not reach the blood pressure goal with this combination, I add diuretic, since the diuretic is not part of the fixed dose combination, we use today indapamide, because indapamide in several studies showed very positive effect on hypertension. And despite the fact that indapamide is very similar to a hydrochlorothiazide, indapamide is much better.  Dr. Ehud Grossman. There are also some fixed-dose combinations of ACE inhibitors with indapamide... Yes, but not in Israel. If you have a combination of ACE inhibitor and indapamide, and you on top of it use a calcium antagonist, or you have an option of ACE inhibitor and calcium antagonist and then on top of it add diuretic indapamide.