Blood Pressure Targets with Antihypertensive Treatment
This chapter discusses the issue of achieving target blood pressure values in uncomplicated and complicated hypertensive patients. The recommendations made in the 2007 by the European guidelines on hypertension, as well as data provided by the most recent
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Giuseppe Mancia
21.1
Introduction
A large number of trials have shown that antihypertensive treatment is associated with a reduction in hypertension-related cardiovascular complications such as stroke, coronary heart disease, heart failure, and renal insufficiency [1]. They have also shown that these beneficial effects can be obtained regardless of the drug or drug combinations used [2, 3] and that a close relationship exists between the magnitude of blood pressure reduction induced by treatment and the cardiovascular protective effect [4]. There is therefore no question that blood pressure must be reduced in individuals with blood pressure elevation, a recommendation made by all international guidelines [1, 5, 6]. How much blood pressure should be reduced by and which should be the target blood pressure values to reach with treatment is much less clear. Epidemiological studies have shown that cardiovascular and renal outcomes continue to decrease to low blood pressure values (approximately 110 mmHg for systolic and 70 mmHg for diastolic) [7]. However, the conclusion that the lower the blood pressure the greater is the cardiovascular and renal protection cannot tout court be applied to antihypertensive treatment because patients with a blood pressure elevation may have structural and functional cardiovascular alterations that reduce the ability of vital organs to autoregulate and preserve their perfusion when blood pressure is lowered [8]. Target blood pressure values must therefore be established in intervention trials, which regretfully have not obtained univocal results.
G. Mancia (&) Centro Interuniversitario di Fisiologia Clinica e Ipertensione, Fondazione Ipertensione e Prevenzione Cardiovascolare, Università Milano-Bicocca, Milan, Italy e-mail: [email protected] A. E. Berbari and G. Mancia (eds.), Special Issues in Hypertension, DOI: 10.1007/978-88-470-2601-8_21, Ó Springer-Verlag Italia 2012
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G. Mancia
This chapter reviews the available evidence on the blood pressure targets to be reached with treatment in hypertensive patients. Emphasis will be given to those blood pressure values recommended by the existing guidelines, i.e., \140/ 90 mmHg in the general hypertensive population and \130/80 mmHg in the high cardiovascular risk one [1].
21.2
Target Blood Pressure Lower Than 140/90 mmHg
Fig. 21.1 Effects of systolic blood pressure (SBP) to values \140 mmHg in patients randomized to more active antihypertensive drug treatment in trials on uncomplicated hypertensive patients (HT, top left panel), older patients (top right panel), patients with diabetes (left bottom panel), and patients with previous cardiovascular disease (CVD) (right bottom panel). In each panel the abbreviations identify the trials considered for the analysis (Figure drawn from data from [10]). CHD coronary heart disease
21.2.1 Randomized Trials in Grade 1 Uncomplicated Hypertension As shown in Fig. 21.1 (upper left panel), in five randomized trials on uncomplicated grade 1 hypertensive patients a variety of an
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