Research on hypertension has achieved, in the last few decades, important results on the pathophysiology, diagnosis and treatment of the high blood pressure (BP) condition. However, as listed in the 2018 European guidelines, several aspects remain unclarified either because they have not been explored by properly designed studies or because data remain controversial.
This presentation will discuss some of the questions that represent important unmet needs for hypertension research. One, absence of randomized evidence-based trials on the benefit of antihypertensive treatment in important clinical conditions such as white coat hypertension, masked hypertension, resistant hypertension, hypertension of the very elderly people (e.g. nonagenarians) and hypertensives classifiable as frail because of the high number of comorbidities and poor life expectancy. Two, hypertension of relatively young people (e.g. < 45 or 40 years) in whom low event incidence prevents the performance of event-based trials, making prevention or progression of subclinical organ damage probably the only reliable and feasible approach. Three, the benefit of funding treatment on out-of-office (ambulatory and/or home) BP either as an alternative or an addition to classical office BP reduction, a fundamental therapeutic issue never addressed in the past. Four, the BP threshold at which to start treatment in naive hypertensives and the goal BP value to try to reach in different demographic and clinical hypertension subgroups. And finally, the problem of residual risk in apparently well treated hypertensive individuals, i.e. their persistence at a risk level clearly higher than that of the control population. A final consideration will be that assessing this issue by randomized trials will probably be difficult and that future research will thus have to rely more and more frequently on observational studies which can now be based on large population data-bases that extend over many years and can, via extensive information and high quality analysis, substantially reduce the risk of the risk of confounding associated with this approach.