Moving Beyond Office Blood Pressure to Achieve a Personalized and More Precise Hypertension Management: Which Way to Go?

Abstract

Blood pressure (BP) has a well-documented, continuous relationship with cardiovascular risk,1 and hypertension has a huge impact at population level in terms of cardiovascular complications and mortality.2 On the other hand, BP reduction in hypertensive subjects is easily achievable and provides dose-dependent prognostic benefits.3 While evidence from large-scale trials represents the backbone for clinical decisions, physicians must strive to achieve a personalized approach to disease management in individual subjects, including those with hypertension and cardiovascular diseases. Indeed, current use of terms such as personalized or precision medicine refers to patients’ care guided by individual molecular characteristics combined with up-to-date diagnostic methods. Specifically, when considering hypertension management, it has been proposed that the intensity of BP lowering should be personalized according to individual cardiovascular risk profile, meaning that (1) prompt BP control should mainly be achieved in high-risk patients; and (2) achievement of lower BP levels may be beneficial in subjects at higher cardiovascular risk. Evidence is available that in high-risk individuals, absolute benefits of treatment are greatest, and pharmacological treatment is more cost-effective.4 On the other hand, when targeting high-risk hypertensive subjects, the large reduction of absolute cardiovascular risk obtained by treatment is accompanied by a considerable residual risk. The latter represents the excess of risk due to the presence of irreversible organ damage, which persists even after achieving optimal control of BP and other risk factors.5 On the contrary, an effective BP reduction by treatment obtained earlier in the clinical history of hypertension, that is in still low-risk individuals, leaves much less residual risk and, thus, offers more solid lifelong cardiovascular protection.5 This kind of reasoning supports the importance of achieving effective and early BP control also in subjects with mild–moderate BP elevations and low cardiovascular risk. Whether lower BP targets are justified …