How important is optimal blood pressure control?

Abstract

BACKGROUND: Evidence for the cardiovascular benefits of antihypertensive treatment is among the strongest in medicine. Randomized, prospective, unconfounded studies in thousands of people have shown that even small reductions in blood pressure for short periods substantially improve cardiovascular outcomes. Recent evidence has emphasized the importance of optimal blood pressure control, particularly in patients with high cardiovascular risk, such as those with type 2 diabetes mellitus. OBJECTIVE: This article discusses optimal target blood pressure goals, reviews the effects of antihypertensive treatment in high-risk patients, presents current guidelines for blood pressure control, discusses the failure worldwide to achieve such control, and suggests approaches to improved treatment. CONCLUSIONS: In high-risk patients, small improvements in blood pressure control are associated with large reductions in cardiovascular risk. National and international guidelines for the management of hypertension therefore now recommend rigorous blood pressure targets. Despite extensive clinical evidence, the delivery of care for hypertension remains unsatisfactory. Hypertension is underdiagnosed and undertreated, and recommended target blood pressures are rarely achieved. Physicians appear reluctant to make changes to treatment, which would lead to more effective use of antihypertensive drugs. Overwhelming evidence supports the benefit of optimal blood pressure control in patients with hypertension. Several studies have shown that such control can be achieved, but most likely requires combination treatment. Combination treatment is likely to be successful only if drugs are well tolerated and patients are compliant. The angiotensin II receptor antagonists (sartans) have the therapeutic advantage of efficacy, excellent tolerability, and a good record of compliance. Blood pressure control can be more easily accomplished by using sartans early in treatment and by recognizing the benefits of even small reductions in blood pressure.