'Hypertension' and Cardiovascular Risk

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US Cardiology, 2006;3(2):1-5

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How low should blood pressure be taken and how soon should treatment be started are key questions in aging and considering cardiovascular mortality risks. But it might be important to ask whether 'hypertensionÔÇÖ is the right word. It has long been taught that one should allow blood pressure to rise to a level deemed 'pre-hypertensiveÔÇÖ or 'hypertensiveÔÇÖ before embarking on non-pharmacologic and pharmacologic therapy. Is this really the right tack in clinical medicine? A more appropriate consideration might be whether or not we should prevent the development of blood pressure elevation through earlier behavioral modification and even pharmacotherapy in some patients. There is no threshold as one looks at epidemiological data; only a continuous relationship between blood pressure and cardiovascular events. As such, the real strategy may be primary prevention.

What the right blood pressure is remains open to question. Epidemiologic evidence would suggest that blood pressures below 120mmHg are least likely to be associated with cardiovascular events,1 whether treatment of patients with higher blood pressures to these levels results in the same cardiovascular risk reduction, and at what cost, must be addressed, along with whether there a trade-off with regard to safety. Only newer clinical trials will be able to answer this question, as this may require more extensive involvement of various pharmacotherapies with their attendant cost and associated risk. Perhaps a more germane issue would be identifying the optimal therapeutic index of a given therapy and blood pressure goal for each patient.

With this background, this article will focus on three basic issues:

  • which blood pressure determinations should be treated;
  • whether ability to provide appropriate behavioral modification recommendations to assist in blood pressure control has been fully optimized; and
  • major future developments in antihypertensive therapy.

The debate about which blood pressures should be treated has been stimulated by newer technologies that now allow patients to monitor blood pressure at home with a multitude of different devices, as well as more sophisticated techniques using 24-hour ambulatory blood pressure measurement to evaluate the influence of diurnal variations in blood pressure as well as the effects of relaxation, exercise, and stress.

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References
  1. Vasan RS, Larson MG, Leip EP et al., Impact of high-normal blood pressure on the risk of cardiovascular disease , N Engl J Med (2001);345: pp. 1291-1297.
    Crossref | PubMed
  2. Clement DL, De Buyzere ML, De Bacquer DA et al., Prognostic value of ambulatory blood-pressure recordings in patients with treated hypertension , N Engl J Med (2003);348: pp. 2407-2415.
    Crossref | PubMed
  3. Kario K, Pickering TG, Umeda Y et al., Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study , Circulation (2003);107: pp. 1401-1406.
    Crossref | PubMed
  4. Chobanian AV, Bakris GL, Black HR et al., The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report , JAMA (2003);289: pp. 2560-2572.
    Crossref | PubMed
  5. Obarzanek E, Proschan MA,Vollmer WM et al., Individual blood pressure responses to changes in salt intake: results from the DASH-Sodium trial , Hypertension (2003);42: pp. 459-467.
    Crossref | PubMed
  6. Sacks FM, Svetkey LP,Vollmer WM et al., Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group , N Engl J Med (2001);344: pp. 3-10.
    Crossref | PubMed
  7. Nesbitt SD, Julius S, Leonard D et al., Is low-risk hypertension fact or fiction? Cardiovascular risk profile in the TROPHY study , Am J Hypertens (2005;18: pp. 980-985.
    Crossref | PubMed
  8. Teerlink JR, Massie BM, Late breaking heart failure trials from the 2003 ACC meeting: EPHESUS and COMPANION , J Card Fail (2003);9: pp. 158-163.
    Crossref | PubMed
  9. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) , JAMA (2002);288: pp. 2981-2997.
    Crossref | PubMed
  10. Weir MR, Chrysant SG, McCarron DA et al., Influence of race and dietary salt on the antihypertensive efficacy of an angiotensin-converting enzyme inhibitor or a calcium channel antagonist in salt-sensitive hypertensives , Hypertension (1998);31: pp. 1088-1096.
    Crossref | PubMed
  11. Weir MR, Angiotensin II receptor blockers: the importance of dose in cardiovascular and renal risk reduction , J Clin Hypertens (Greenwich) (2004);6: pp. 315-323.
    Crossref | PubMed
  12. Weir MR, Providing end-organ protection with renin-angiotensin system inhibition: the evidence so far , J Clin Hypertens (Greenwich) (2006);8: pp. 99-105.
    Crossref | PubMed
  13. Bakris GL,Weir MR, Achieving goal blood pressure in patients with type 2 diabetes: conventional versus fixed-dose combination approaches , J Clin Hypertens (Greenwich) (2003);5: pp. 202-209.
    Crossref | PubMed