Antihypertensive treatment: should it be titrated to blood pressure reduction or to target organ damage regression?

Abstract

The success of an antihypertensive treatment is difficult to estimate by the extent of blood pressure reduction alone. Above and beyond blood pressure values in an individual patient, it is necessary to monitor the impact of antihypertensive treatment on the development or regression of hypertension-induced early end-organ damage. The intermediate objectives or surrogate endpoints may provide additional valuable information about the level of success of a given therapy in a particular patient. Moreover, monitoring intermediate objectives may provide scientific evidence for delineating the best antihypertensive treatment. The importance of assessing left ventricular mass, microalbuminuria, carotid wall thickness and the development of new-onset diabetes during antihypertensive treatment has been stressed. Left ventricular hypertrophy during antihypertensive therapy is associated with a lower likelihood of cardiovascular morbidity and mortality, independent of blood pressure lowering and treatment modalities in people with essential hypertension. Likewise, a reduction in urinary albumin excretion seems to be followed by a reduction in cardiovascular morbidity and mortality. Risk implications of reducing carotid wall thickness or of developing new-onset diabetes have been more controversial, although it seems to be that both can have a desirable effect. The available findings support the necessity to monitor intermediate objectives, aside from blood pressure measurement, during the follow-up of hypertensives.