Treatment of Hypertension: Which Goal for Which Patient?

Abstract

Hypertension remains the most important risk factor for cardiovascular disease. If antihypertensive drugs choice is well guided today, blood pressure (BP) target still a subject of controversies. Residual risk is matter of debate and the lower- the better dogma is come back again regarding to data reported from recent trials. The J curve, reason for European Society of Hypertension Guidelines reappraisal in 2009, is criticized by recent data. The one goal (<140/90 mmHg) fit 90 mmg 90 mmHg) fit all should be adapted as a personalized goal guided by evidence generated by randomized controlled trials. Target controversy is back because of the results of ACCORD and SPRINT trials challenging the common systolic BP target less 140 mmHg to less than 120 mmHg. The first was performed in diabetic patients and the second in patients at high cardiovascular risk; elderly aged of 75 years and above, or patients with chronic kidney disease, or with pre-existing subclinical or clinical cardiovascular disease or a Framingham 10-year cardiovascular disease risk score of 15 % or above, however non diabetic. If the first trial was negative, SPRINT reports a huge reduction of the composite primary outcome, which included myocardial infarction, other acute coronary syndromes, stroke, heart failure or death from cardiovascular causes by 25 %, and the risk of death from all causes by 27 %, when target systolic BP is lower than 120 mmHg compared to lower than 140 mmHg. However, BP was measured by automated office BP technique which correlates more with home BP measurement than auscultatory office BP measurement. Also, only significant less heart failure in the intensive arm was driving the difference in mortality favoring the intensive arm in SPRINT. The greater use of diuretics may have demasked latent heart failure in hypertensive patients with rather high cardiovascular risk.

More convincing data suggest that BP should be diagnosed early and treatment should be started at BP level of 140 mmHg and above, based on an office BP measurement, confirmed by an out-of-office BP measurement. Target systolic BP should be less than 140 mmHg if BP is measured by classic auscultatory method, less than 120 mmHg in high risk patients if BP is measured by automated office BP measurement. These targets are relevant in elderly patients if no orthostatic hypotension occurred, patients with non proteinuric chronic kidney disease (eGFR < 60 ml/mn/1.73 m²) and patients with cardiovascular disease or a Framingham score more than 15 %. However attention should be taken on diastolic BP if lower than 70 mmHg because of an increasing risk of ischemic heart event and on renal function since acute renal failure is more frequently reported at these low targets.

In diabetic patients, SBP target should be less than 140 mmHg according to ACCORD trial. However, for patients with protein-creatinine ratio >500 mg/g (albumin-creatinine ratio > 300 mg/g), with or without diabetes, lower SBP target should be proposed for renal protection aiming SBP < 130 mmHg as recommended by KDIGO guidelines.

In patients at low or intermediate risk, without cardiovascular disease, SBP should start to be treated when SBP is above 140 mmHg, and when treated, target BP should be less than 140 mmHg as reported by HOPE-3 trial.