Management of “Hypertension” Based on Blood Pressure Level Versus an Absolute Cardiovascular Risk Approach

  • Mark NelsonEmail author
Antihypertensive Agents: Mechanisms of Drug Action (Michael E. Ernst, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Antihypertensive Agents: Mechanisms of Drug Action


Purpose of Review

To address the tension between guideline recommendations and the evidence from clinical trials supporting them and clinician concerns of overtreatment of elevated blood pressure.

Recent Findings

Systolic Blood Pressure Intervention trial (SPRINT) demonstrated lower blood pressure targets provided robust clinical benefit (reduced all-cause mortality) but also expected adverse events due to hypotension. Treatment thresholds for systolic blood pressure in the latest US guidelines have been lowered to 130 mmHg, although this has not been adopted elsewhere. These guidelines specify that treatment in the 130 s should be considered in the setting of absolute risk, i.e. treatment should be directed to those at high risk. This review argues that this hybrid approach, treatment thresholds in the 130 s based on absolute risk and above 140 mmHg on blood pressure level alone is a compromise, and that risk stratification should be the basis of drug treatment decision-making unless blood pressure is very high.


Who receives blood pressure lowering medication is best determined by who is most likely to have a heart attack or stroke in the intermediate period rather than medicalising individuals who have a mildly elevated blood pressure.


Hypertension Risk stratification Clinical decision-making 


Compliance with Ethical Standards

Conflict of Interest

The author declares no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Menzies Institute for Medical ResearchUniversity of TasmaniaHobartAustralia
  2. 2.School of MedicineUniversity of TasmaniaHobartAustralia

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