From Treating Hypertension to Lowering Cardiovascular Disease Risk

Traditionally, clinical practice guidelines have relied primarily on a blood pressure (BP) threshold when identifying individuals for whom to recommend BP-lowering medications. 1 This approach is clinically intuitive and, since historical trials included only persons with very high BP, was easy to implement with little safety concerns such as hypotension or syncope.Grimley Evans and Geoffrey Rose famously defined hypertension as, "a blood-pressure level above which investigation and treatment do more good than harm". 2 Over time, trials have demonstrated the potential cardiovascular disease (CVD) benefits of BP-lowering treatment at lower and lower pre-treatment BP values, 1 to the point where contemporary trials have included persons with pre-randomization BP threshold values (e.g., systolic BP ≥130 mm Hg) that many clinicians do not consider "hypertensive" and on-treatment BP targets (e.g., systolic BP <120 mm Hg) where traditionally concerns about safety due to iatrogenic hypotension had been raised.In parallel with these lower BP target trials, many of the same BP-lowering medications (most notably renin-angiotensin system inhibitors) have also been tested in trials of patients with, for example, ischemic heart disease and/or systolic heart failure where these medications were not being studied for their BP-lowering properties but rather for other salient effects such as reverse remodelling of the left ventricle.These trials included persons without pre-randomization BP values in the traditionally hypertensive range and, in that context, provide a second line of investigation into more intensive lowering of BP.