How should treated hypertensive patients with systolic blood pressure below 120 mmHg be managed?

This commentary refers to ‘2018 ESC/ESH Guidelines for the management of arterial hypertension’, by B. Williams et al., 2018;39:3021–3104. New European Society of Cardiology/European Society of Hypertension guidelines for the management of arterial hypertension were recently published.1 One major novelty was that office systolic blood pressure (SBP) should not be targeted to values <120 mmHg in treated patients, due to a higher risk of adverse events. Although not providing formal out-of-office blood pressure (BP) targets, new guidelines suggested that differences between office and out-of-office SBP become negligible <120 mmHg.1 This could lead to the interpretation that treated patients with office or home SBP <120 mmHg are at increased risk of adverse events. Therefore, estimating the magnitude of treated patients with office and/or home SBP <120 mmHg in clinical practice is an important task. To address this issue, we evaluated 2839 treated Brazilian hypertensive individuals (age = 57.7 ± 14.5 years, 44% men) from two cardiology centres who underwent home BP monitoring from March 2005 to February 2018. This study was approved by the Oswaldo Cruz University Hospital/PROCAPE Complex ethics committee. Among all studied patients, 1888 (66%) had office and home SBP ≥120 mmHg, 299 (11%) had office and home SBP <120 mmHg, and 111 (4%) and 541 (19%) had SBP <120 mmHg exclusively at the office and home, respectively (Figure 1). Notably, among 1213 patients with controlled office SBP (≥120 and <140 mmHg)1 and 1216 patients with uncontrolled office SBP (≥140 mmHg),1 442 (36%) and 99 (8%) had home SBP <120 mmHg, respectively. Relationship between office and home systolic blood pressure. These findings suggest that the proportion of treated patients with office or home SBP <120 mmHg is not negligible. They further indicate that out-of-office BP monitoring, which is strongly encouraged by the new guidelines,1 may reveal numerous patients with controlled or uncontrolled office SBP, but with home SBP <120 mmHg. Although a J-curve association between office BP and adverse outcomes has been extensively reported in treated patients,1 available data precludes a definite conclusion for home BP. However, a J-curve relationship between home BP measures and clinical events have been also suggested in samples showing high prevalence of treated hypertension, with a higher risk apparently below the range of 115–124 mmHg.2 Based on these data, some intuitive questions may arise: (i) should the dosing of antihypertensive medication be reduced in treated patients with office SBP already <120 mmHg to move their BP onto target range? (ii) Should treated patients with home SBP <120 mmHg be considered at a risk similar to those with office SBP <120 mmHg? Clarification of these issues might help physicians to manage their patients in the light of the new European Society of Cardiology/European Society of Hypertension guidelines. The study was supported by the CNPq [grant 306154/2017-0 to W.N.]. Conflict of interest: none declared.