High blood pressure: what level to treat?

Recent trials of the treatment of mild hypertension have suggested that there may be benefit from drug treatment of quite modest or borderline levels of pressure. Drug treatment of subjects with diastolic pressures over 95 mm Hg would pose a major problem in the efficient organization of such a long-term program and would also be costly. Perhaps about 350 patient years of treatment might be necessary to prolong one patient's life by 1 year. The side effects as well as the costs of such a program should make us cautious about offering such treatment solely on the results of measurement of arterial pressure. In people with diastolic pressures in the range of 90-100 mm Hg we should carefully consider several factors such as age, sex, cholesterol concentrations, diabetes, family history, and smoking habit which might also interact to identify particularly high risks and exclude those individuals with a particularly benign prognosis. The results of the more recent trials can give very little information about such subgroup analysis, which would be possible only with much larger samples. The untreated subjects with raised pressure should be carefully followed and offered advice on nondrug strategies such as weight reduction, treatment of lipid abnormalities, and reduction in dietary salt intake. This type of program demands careful, possibly computerized, records and follow-up.