Key result
Targeting vascular dysfunction beyond blood pressure reduction may refine risk stratification in hypertension.
Why the study?
Substantial residual cardiovascular risk persists under traditional pressure-centric hypertension management, prompting a proposed shift to a vessel-centric paradigm.
Shifting from a pressure-centric to a vessel-centric paradigm in hypertension management may better address residual cardiovascular risk by targeting underlying vascular dysfunction.
Answers are grounded in this paper and cite their sources.
May support vascular assessment in hypertension; leaves open whether targeting dysfunction improves outcomes beyond BP control.
Hypertension has traditionally been defined and managed according to brachial blood pressure levels. Although this pressure-centric strategy has significantly reduced cardiovascular morbidity and mortality, substantial residual risk persists even among patients who achieve recommended blood pressure targets. Emerging evidence indicates that hypertension is fundamentally a systemic disorder of the vascular wall, in which endothelial dysfunction, oxidative stress, immune activation, microvascular remodeling, and progressive arterial stiffening not only result from elevated pressure but also actively drive its initiation and progression. Endothelial nitric oxide deficiency, redox imbalance with endothelial nitric oxide synthase uncoupling, T helper 17 cell-mediated inflammation, and mineralocorticoid receptor–dependent vascular signaling collectively promote increased vascular tone and structural remodeling. Microvascular rarefaction elevates peripheral resistance, while large-artery stiffening augments central pulsatile load and accelerates target organ injury. These interconnected processes create a self-reinforcing network that sustains hypertension beyond simple hemodynamic elevation. In this review, I propose a shift from a pressure-centric to a vessel-centric paradigm of hypertension. I describe mechanistically defined vascular phenotypes, discuss macrovascular and microvascular assessment strategies, and explore therapeutic approaches aimed at vascular restoration in addition to blood pressure reduction. I further examine the concepts of vascular age, residual risk, and precision vascular medicine, and consider future integration of artificial intelligence and vascular endpoints into clinical trials. Recognizing vascular dysfunction as a central determinant of hypertension may refine risk stratification, redefine therapeutic success, and represent the next frontier in cardiovascular medicine.
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Yukihito Higashi (2026) conducted a review in Hypertension. Recognizing vascular dysfunction as a central determinant of hypertension, rather than relying solely on blood pressure reduction, may refine risk stratification and redefine therapeutic success.
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