The lowest well tolerated blood pressure: A personalized target for all?
Paolo Verdecchia1, Fabio Angeli2, Gianpaolo Reboldi3
1Fondazione Umbra Cuore e Ipertensione-ONLUS, Perugia, Italy; Department of Cardiology, Hospital S. Maria della Misericordia, Perugia, Italy.
Insights
Determining the optimal blood pressure (BP) target for hypertension management is complex. Personalized, well-tolerated BP goals balance efficacy and safety, as evidence for fixed targets is limited.
Area of Science:
- Cardiology
- Hypertension Management
- Clinical Evidence Synthesis
Background:
- Optimal blood pressure (BP) targets for preventing cardiovascular complications in hypertension lack definitive evidence.
- Current guidelines offer varied BP targets based on patient factors, but supporting data is often weak.
Purpose of the Study:
- To review the evidence base for selecting blood pressure targets in hypertensive patients.
- To discuss the challenges and considerations in defining optimal BP goals.
Main Methods:
- Analysis of randomized strategy trials comparing intensive versus less intensive BP targets.
- Evaluation of evidence supporting different BP thresholds and their clinical implications.
Main Results:
- More intensive BP treatment targets generally reduced major cardiovascular event risk.
- Intensive targets were associated with increased adverse effects like hypotension and renal dysfunction.
Conclusions:
- Fixed BP targets lack robust evidence due to data heterogeneity.
- Personalized BP targets, prioritizing the lowest well-tolerated level, offer the best efficacy-safety trade-off.
Abstract:
The optimal blood pressure (BP) target for prevention of cardiovascular complications of hypertension remains uncertain. Most Guidelines suggest different targets depending on age, comorbidities and treatment tolerability, but the underlying evidence is not strong. Results of randomized strategy trials comparing lower (i.e., more intensive) versus higher (i.e., less intensive) BP targets should drive the definition. However, these trials tested different BP targets based on systolic BP, diastolic BP or combined systolic and diastolic BP goals. Overall, the more intensive treatment targets reduced the risk of major cardiovascular complications of hypertension when compared with the less intensive targets, despite a higher incidence of unwanted effects including, but not limited to, hypotension, electrolyte abnormalities and renal dysfunction. Consequently, some Guidelines defined low BP thresholds (i.e., 120/70 mmHg) not to exceed downward because of the expectation that unwanted effects may outweigh the outcome benefits. The present review discusses the evidence underlying the choice of BP targets, which remains an important step in the management of hypertensive patients. We conclude that, on the ground of the heterogeneity of available data in support to fixed BP targets, their definition should be personalized in all patients and based on best trade-off between efficacy and safety, i.e., the lowest well tolerated BP.
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