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Hypertension
Developments in Strategies for Treating High-risk Hypertension
Cristina Sierra and Antonio Coca
Hypertension Unit, Department of Internal Medicine, Institute of Medicine and Dermatology, Hospital Clinic (IDIBAPS), University of Barcelona
Abstract
On the basis of current evidence provided by various studies, the most recent international guidelines recommend reducing blood pressure
levels to below 140/90mmHg for all hypertensive patients over 18 years of age, including the elderly, when this is clinically tolerated, as a
necessary measure to reduce the global cardiovascular risk, which is the fundamental objective of treatment. For high-risk hypertensives,
such as patients with diabetes, patients with silent target organ damage or established clinical cardiovascular disease, levels below
130/80mmHg should be reached and maintained, with even lower levels for patients with established renal disease and proteinuria within
the nephrotic range. Blood pressure control in high-risk patients should be achieved as rapidly as possible using initial strategies that
include combinations of antihypertensive drugs, and also the best drugs and drug combinations with proven capacity to regress silent
organ damage and to interrupt the progression of cardiovascular disease. This must be accompanied by the additional lifestyle measures
and drugs necessary to control other associated cardiovascular risk factors. In clinical practice this means that, together with
renin–angiotensin–aldosterone system (RAAS) blockade, often associated with calcium-channel blockade, statins and antiplatelet drugs
should routinely be administered in most patients, particularly those over 55 years of age, as they provide the only possibility of global risk
prevention leading to greater survival.
Keywords
Essential hypertension, cardiovascular disease, target organ damage, cardiovascular risk stratification, antihypertensive treatment
Disclosure: The authors have no conflicts of interest to declare.
Received: 13 May 2009 Accepted: 28 May 2009
Correspondence: Antonio Coca, Hospital Clinic, C/Villarroel 170, 08036, Barcelona, Spain. E:
acoca@clinic.ub.es
Hypertension Treatment high to normal BP hypertension, mild (grade 1), moderate (grade 2)
The aim of antihypertensive treatment is to reduce the hypertension or severe (grade 3) hypertension.
cardiovascular morbidity and mortality associated with high blood
pressure (BP) levels by measures aimed at reducing BP levels and From this perspective, the ESH/ESC guidelines
1
include a table to
minimising the impact of possible associated risk factors or calculate the total absolute risk in subjects with normal and high
co-morbidities.
1–5
This therapeutic goal requires previous to normal BP values and in patients with mild, moderate or severe
cardiovascular risk stratification to assess the global risk of hypertension. This approach classifies the added risk in terms of
hypertensive patients, followed by the determination of BP values to low, moderate, high and very high added risk, indicating an absolute
start treatment (threshold BP) and BP values to be achieved by 10-year risk of cardiovascular disease of <15, 15–20, 20–30 and
antihypertensive treatment (BP target). Both aspects are closely >30%, respectively, according to the Framingham score criteria
related to the total cardiovascular risk of the patient, which may be (FSC), coinciding with an absolute 10-year risk of cardiovascular
calculated by using different risk stratification tables. mortality of <4, 4–5, 5–8 and >8%, respectively, according to the FSC
(see Table 1).
The relationship between the level of BP and cardiovascular risk makes
any numerical definition and classification of hypertension arbitrary. The primary goal of treatment of patients with high BP is to achieve
The operational definition offered by Geoffrey Rose more than 30 years the maximum reduction in long-term total risk of cardiovascular
ago – hypertension should be defined in terms of a BP level above morbidity and mortality. This requires treatment of all of the reversible
which investigation and treatment do more good than harm – also risk factors identified, including smoking, dyslipidaemia or diabetes,
indicates that any numerical definition must be flexible, resulting from and the appropriate management of associated clinical conditions, as
evidence of risk and the availability of effective and well-tolerated well as treatment of the raised BP.
treatment. Due to these considerations, it would perhaps be more
correct to use a classification of BP levels without the term In terms of BP reduction, it seems logical that the aim of
hypertension. The European Society of Hypertension/European Society antihypertensive treatment should be to reduce BP to the lowest
of Cardiology (ESH/ESC) guidelines
1
use a combined approach to this values tolerated by the patient, given that the relationship between
concern, defining five categories for the classification of BP: normal/ BP levels and cardiovascular risk is continuous. Both the seventh
56 © TOUCH BRIEFINGS 2009
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