[Should substitution criteria be used in hypertensive disease?]

A number of methods, some of which are still in the development phase, enable progressively more accurate assessment of structural and/or functional changes of the target organs of hypertension. The notion that these changes may be used as a substitution criterion in the evaluation of hypertensive disease is at the heart of the concept of preclinical cardiovascular disease: in its theoretical and practical aspects, this concept stipulates that the preclinical disease is an intermediate stage between exposure to the risk factor of hypertension and the advant of morbid or mortal cardiovascular events, and it suggests that the evaluation of the preclinical disease leads to a more accurate stratification of cardiovascular risk than measurement of the risk factors alone. However, at present, none of the parameters proposed (albuminuria, left ventricular mass, arterial wall thickness) is a validated substitution criterion; but many arguments indicate that the use of these parameters as intermediate criteria is justified under certain conditions.