Treatment Thresholds and Targets in Hypertension: Different Readings of the Same Evidence?

Abstract

See related article, pp e13–e115 The new 2017 High Blood Pressure Clinical Practice Guideline released by the American College of Cardiology (ACC) and the American Heart Association (AHA)1 presents several novel aspects with potential significant impact on hypertension management. Important news of the guideline is related to blood pressure (BP) measurement modalities, BP thresholds for the initiation of nonpharmacological as well as pharmacological treatment, BP targets to pursue to maximize treatment benefits from BP lowering and last but not least a novel definition of hypertension. Overall, this is an important document but its translation into clinical practice seems to pose a huge challenge for clinicians According to the novel definition of stage 1 hypertension starting at systolic or diastolic BP values of ≥130 mm Hg or ≥80 mm Hg almost 50% of adults in the US population (and in many other countries around the world) have hypertension, whereas the remaining 50% resides either in the elevated (ie, 120–129 mm Hg) or in the normal systolic BP range (ie, <120 mm Hg). Given that BP thresholds and targets are inevitably related to the hypertension definition, the new selected threshold (ie, 130/80 mm Hg) will introduce an epidemiological revolution that will not remain unquestioned in the United States and around the world. Beyond the immediate overnight striking increase (by 14%) of hypertension prevalence in the United States after the presentation of the new guideline, the incidence rate of hypertension is expected to decrease because of the increased disease duration, as the new diagnosis of hypertension is expected to be anticipated at a younger age. It is, however, questionable whether diagnosing hypertension in younger otherwise healthy subjects by tightening up the hypertension definition will indeed improve prevention strategies, for example, by lifestyle modifications, as intended by the authors of the guideline. In …