Should Patients With Cardiovascular Risk Factors Receive Intensive Treatment of Hypertension to

Abstract

Opposing Viewpoint, see p 1308 Epidemiologic studies show a graded increase in risk at systolic blood pressure (BP) >115 mm Hg and diastolic BP >75 mm Hg. However, it remains unclear whether pharmacologic BP lowering to these levels reduces cardiovascular (CV) events and is safe. Observational analyses raised concerns about aggressive BP lowering to levels <120/80 mm Hg, suggesting the existence of a J-curve phenomenon with increased risk especially for coronary events. However, such analyses are potentially confounded. More reliable data are provided by randomized trials. Most BP-lowering trials have evaluated patients with high pretreatment BP and have rarely achieved average systolic BP <130 to 140 mm Hg, except in patients with high-risk CV disease, such as recent myocardial infarction (MI) or heart failure (HF) or those with chronic kidney disease. Three recent trials have specifically compared intensive systolic BP lowering to targets of <120 to 130 mm Hg versus traditional guideline recommended targets of generally <140 mm Hg,1–3 while the older HOT trial (Hypertension Optimal Treatment) randomized patients to diastolic BP targets of ≤90, ≤85, or ≤80 mm Hg.4 These trials differ significantly in their design, patients’ characteristics and CV risk, BP regimens, duration of treatment, primary outcomes, BP measurement techniques, and results. The ACCORD trial (Action to Control Cardiovascular Risk in Diabetes) randomized 4733 patients with diabetes (mean 63 years of age, 34% with a previous CV event, BP 139/76 mm Hg) to intensive therapy to a systolic BP target <120 mm Hg or to a standard target <140 mm Hg.1 Intensive therapy lowered BP by …