Decisions about antihypertensive treatment should focus on reducing cardiovascular risk

Epidemiological studies 1 Lewington S Clarke R Qizilbash N Peto R Collins R Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002; 360: 1903-1913 Summary Full Text Full Text PDF PubMed Scopus (7223) Google Scholar , 2 Rapsomaniki E Timmis A George J et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people. Lancet. 2014; 383: 1899-1911 Summary Full Text Full Text PDF PubMed Scopus (819) Google Scholar provide strong evidence for an association between high blood pressure and fatal cardiovascular complications, and interventional studies have shown that antihypertensive treatments reduce cardiovascular events and all-cause mortality. 3 Thomopoulos C Parati G Zanchetti A Effects of blood pressure lowering on outcome incidence in hypertension. 1. Overview, meta-analyses, and meta-regression analyses of randomized trials. J Hypertens. 2014; 32: 2285-2295 Crossref PubMed Scopus (167) Google Scholar , 4 Ettehad D Emdin CA Kiran A et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016; 387: 957-967 Summary Full Text Full Text PDF PubMed Scopus (1541) Google Scholar Although the target blood pressure for patients with hypertension receiving treatment in the current US guidelines 5 Whelton PK Carey RM Aronow WS et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol. 2018; 71: e127-e248 Crossref PubMed Scopus (2007) Google Scholar is less than 130/80 mm Hg and European recommendations indicate achieving 120–129/70–79 mm Hg for people younger than 65 years (and 130–139/70–79 mm Hg for those ≥65 years), 6 Williams B Mancia G Dessormais E et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. The task force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). J Hypertens. 2018; 36: 1953-2041 Crossref PubMed Scopus (1073) Google Scholar other guidelines such as those from the UK 7 National Institute for Health and Care ExcellenceHypertension in adults: diagnosis and management. NICE Guideline 136. National Institute for Health and Care Excellence, London2019https://www.nice.org.uk/guidance/ng136Date accessed: April 4, 2021 Google Scholar recommend higher target values for treatment. Thus, threshold blood pressure levels for initiating therapy and target blood pressure levels with treatment remain controversial. Furthermore, the effect of initial blood pressure on outcome, and the benefit for patients treated in primary versus secondary prevention settings have not been settled. 4 Ettehad D Emdin CA Kiran A et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016; 387: 957-967 Summary Full Text Full Text PDF PubMed Scopus (1541) Google Scholar , 8 Brunström M Carlberg B Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: a systematic review and meta-analysis. JAMA Intern Med. 2018; 178: 28-36 Crossref PubMed Scopus (177) Google Scholar Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysisIn this large-scale analysis of randomised trials, a 5 mm Hg reduction of systolic blood pressure reduced the risk of major cardiovascular events by about 10%, irrespective of previous diagnoses of cardiovascular disease, and even at normal or high–normal blood pressure values. These findings suggest that a fixed degree of pharmacological blood pressure lowering is similarly effective for primary and secondary prevention of major cardiovascular disease, even at blood pressure levels currently not considered for treatment. Full-Text PDF Open Access