Hypertension Guidelines: Is It Time to Reappraise Blood Pressure Thresholds and Targets?

Since 1966, a large number of trials of blood pressure (BP) lowering drugs compared with placebo (or no treatment) in hypertensive patients, complemented by trials of more versus less intense BP lowering, have shown that antihypertensive treatment can significantly reduce the incidence of fatal and nonfatal events associated with hypertension.1 A meta-analysis of all BP-lowering trials from 1966 to end of 2013 (68 trials in 245 885 individuals) has calculated that a 10/5 mm Hg systolic BP/diastolic BP (SBP/DBP) reduction significantly decreases stroke by 36%, heart failure by 38%, coronary events by 20%, cardiovascular mortality by 16%, and all-cause mortality by 10%.2 In addition, head-to-head comparisons between treatments based on different antihypertensive drugs (meta-analyses of 50 trials with 58 two-drug comparisons in 247 006 individuals) have shown that what really matters for preventing cardiovascular events is lowering of BP, and how BP is lowered (ie, the types of drugs used) is of minor importance.3 Despite the very large number of trials of antihypertensive treatment, it must be recognized that, except for the benefits of reducing high BP and for the equivalence of the various classes of antihypertensive agents, the majority of questions of practical importance that doctors ask themselves every day when treating hypertension have not been approached by randomized controlled trials or have remained unanswered.1–4 Examples of these unanswered questions are those to be discussed below such as initiation of drug treatment of hypertension, the BP targets to be aimed at, and the role of overall cardiovascular risk in treatment decisions. Although the safest decisions are those that can be found according to results of randomized trials, their concordance, and/or meta-analyses, other decisions should necessarily be taken on the basis of other criteria such as post hoc analysis of trials, observational studies, pathophysiological and pharmacological knowledge, …