[New treatment strategies for hypertension. Which guidelines and how to apply them]

The diagnosis of hypertension by blood pressure measurements taken in the physician's office has been called into question by several studies. The onset of cardiovascular events appears to correlate better with ambulatory blood pressure measurements than with those taken during consultation (either "white coat" or masked hypertension). While the US, WHO, French and European guidelines diverge as to the specific antihypertensive drug among the seven classes available should be chosen for first-line treatment, there is a consensus for specific choices as a function of the type of hypertension. In any case, most treatment trials show that more than two antihypertensive drugs are often necessary. Treatment can thus begin with two drugs. The optimal target blood pressure is defined by the US JNC7 according to whether the patient also has diabetes or a nephropathy. When hypertension is uncomplicated, the target level is 140/90 mmHg. In the case of diabetes or nephropathy, it is 130/80 mmHg. In all cases, diet and exercise changes are also necessary and it is essential that patients understand them if they are to comply with them. Diastolic blood pressure remains the most important figure for those younger than 50 years, but afterwards, systolic pressure is more relevant. Aortic pressure may be more closely associated with cardiovascular risk than the blood pressure measured at the brachial artery. The concept of comprehensive management is radically modifying our behavior : the hypertensive patient is now above all a patient at high cardiovascular risk and the treatments to consider must not be limited to antihypertensive drugs but must also include treatment of other cardiovascular risk factors (aspirin, statins, smoking cessation, etc.).