Blood pressure and cardiovascular disease: what remains to be achieved?

Despite dramatic improvements in the management of hypertensive cardiovascular disease, much remains to be accomplished. Arterial stiffness, through its effects on central aortic pressure, is a key determinant of increased cardiovascular risk. Increased pulse pressure is a late manifestation of increased arterial stiffness. What is needed is a simple, reliable, non-invasive method of detecting early disturbances in central artery stiffness at a time when therapeutic intervention can be most beneficial. Currently, intervention studies support initiating antihypertensive therapy in uncomplicated hypertension when systolic blood pressure > or = 160 mmHg, whereas the benefit of treating systolic blood pressure of 140-159 mmHg, the largest subset of persons with hypertension, has yet to be tested in controlled trials. Further studies are needed to determine the optimal target goal for blood pressure reduction in both uncomplicated hypertension and in hypertension complicated by diabetes, coronary heart disease, or renal disease. Angiotensin converting enzyme inhibitors may provide selective cardiac and renal protection beyond their blood pressure-lowering effect in the presence of specific cardiovascular disease and/or diabetes. In contrast, there is as yet no definitive answer as to the relative benefit of blood pressure lowering versus specific drug effects in minimizing cardiovascular events in uncomplicated hypertension. Although there has been a recent increase in hypertension awareness and treatment, only a small percentage of affected individuals are being treated to goal. Hypertensive cardiovascular disease represents a world-wide public health challenge that can be solved only by new innovative measures aimed at both prevention and treatment.