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New threshold and target blood pressures in the hypertension guidelines. Which implications for the hypertensive population?

Mancia, Giuseppe

doi: 10.1097/HJH.0000000000000513

IRCCS Istituto Auxologico Italiano, Milan and University of Milano-Bicocca, Milan, Italy

Correspondence to Prof Giuseppe Mancia, Piazza dei Daini, 4, 20126 Milano, Italy. Tel: +39 039 233 3357; fax: +39 039 322274; e-mail:

As clinicians and investigators involved in hypertension know, both the European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines published in 2013 [1] and the Joint National Committee (JNC) 8 guidelines published in 2014 [2] adopted a more conservative view on the blood pressure (BP) threshold at which to start antihypertensive drug treatment. Revising the previous recommendation to adopt a lower threshold (<130/80 mmHg) in patients at high cardiovascular risk [3], the 2013 ESH/ESC guidelines recommend to never start drug treatment if BP is lower than 140 mmHg (systolic) or 90 mmHg (diastolic). They also warn that if patients with grade 1 hypertension (BP between 140 and 159/90–99 mmHg) have a low-to-moderate cardiovascular risk or are in the elderly age range, the beneficial effects of lowering BP are not fully documented and thus no strong recommendation in favour of antihypertensive drug use can be issued. Along the same lines, the JNC 8 guidelines state that treatment should always start at a BP of at least 140/90 mmHg, except in elderly hypertensive patients (age ≥60 years) in whom a threshold at least 150/90 mmHg is recommended. The ESH/ESC guidelines also raise the SBP target to be reached with treatment to lay below 140 mmHg (rather than below 130 mmHg) in young and middle-aged hypertensive patients with high cardiovascular risk, and both guidelines recommend a higher SBP target, that is, less than 150 mmHg, in elderly hypertensive patients [1,2].

The new threshold and target BP adopted by the European and American guidelines have raised the issue of how the new values modify the number of patients in need of antihypertensive drug treatment as well as that of patients in whom treatment is regarded as satisfactory and no more efforts to reduce BP values by additional drugs are required. Following a previous publication that focused on the consequences of the new JNC recommendations for the American population [4], this issue of the Journal of Hypertension includes the review by Marques-Vidal et al.[5] in which data from a Swiss population are reported. As expected, the increased threshold for drug treatment adopted by the two recent guidelines was found to have a major impact on the number of patients in need of antihypertensive drugs, and thus on the cost of antihypertensive treatment for the healthcare system. The raised BP threshold adopted by the JNC 8 guidelines for the elderly population reduced the number of elderly patients eligible for treatment by about 25% (from 62.3 to 46.8% of elderly individuals), with a saving of 134.5 million Euros in drug cost. The raised BP threshold adopted by the ESH/ESC guidelines for patients with chronic kidney disease, diabetes or a cardiovascular disease history reduced the number of high cardiovascular risk patients eligible for treatment by about 26% (from 73.6 to 55.6% of the high-risk individuals), with a saving of 71.4 million Euros. Finally, in the elderly and high cardiovascular risk categories the number of patients at goal BP increased by 24 and 33%, respectively, with, thus, a much lower need to increment drug administration, and a further cost-saving effect. These calculations offer healthcare providers valuable information on how future healthcare resources may be properly reallocated between different therapeutic areas in the European continent.

Two other points made by or related to the review of Marques-Vidal et al.[5] deserve to be mentioned. The first point is that the data provided by Marques-Vidal et al.[5] generate the impression that the ESH/ESC guidelines have a much lesser impact on the number of patients no more eligible for drug treatment than the JNC8 guidelines because their modification is limited to a raised BP threshold for treatment in high cardiovascular risk individuals, whereas in the JNC8 guidelines it extends to a highly prevalent hypertensive category such as the elderly. This is not exactly the case, however [6]. One, the 2013 ESH/ESC guidelines do emphasize that trials performed in elderly hypertensive patients have invariably included only patients with a SBP at least 160 mmHg and that, thus, no firm evidence exists to give antihypertensive drugs in elderly individuals with grade 1 hypertension. Unlike the JNC8 guidelines, the European guidelines do not completely exclude the possibility of antihypertensive drug administration also to elderly patients in this BP category. They make it clear, however, that this is feasible only if treatment is well tolerated and is based on a much lower level of evidence (subgroup and post hoc data), thereby not representing the main guidelines recommendation, which is to use antihypertensive drugs in grade 2 or 3 elderly hypertensive patients. Two, as previously mentioned, the European guidelines emphasize that limited evidence exists that drug treatment has beneficial effects in grade 1 hypertensive patients at low-to-moderate cardiovascular risk, a common hypertension category particularly when patients are young or middle aged. In these patients the European recommendation is to reduce BP by means of lifestyle changes and to only resort to drugs if prolonged attempts to control BP by nonpharmacological measures fail and/or some aggravating factors (such as an increased out-of-office BP) are detected. The 2013 ESH/ESC guidelines are, thus, likely to reduce the number of hypertensive patients eligible for drug treatment to a degree similar to the JNC8 guidelines, with a potentially similar reduction in drug-related costs. Indeed, the 2013 ESH/ESC guidelines may have a greater cost-saving effect because of a smaller number of young or middle-aged hypertensive patients (those at low-to-moderate cardiovascular risk responding to nonpharmacological measures) in need of prompt or permanent drug treatment.

The second question is whether the new threshold and target BP values at which to start and aim treatment, respectively, will continue to effectively counteract the increased risk of cardiovascular and renal events associated with hypertension or result, as some investigators believe [7], in lesser protection, thus, negatively affecting primary and secondary cardiovascular preventive strategies and increase, via a raised number of events, long-term healthcare costs. As correctly reported by both the European and the American guidelines, no solid evidence exists to justify the lower BP threshold and targets adopted in the past. However, it cannot be denied that on these important issues data are limited and that the possibility that lower target BP values have a greater protective effect on some hypertension-related complications (e.g. stroke) [8,9] or in some patients’ categories (e.g. young or middle-aged low risk patients with a recent hypertension or diabetes) cannot be excluded. Furthermore, the argument should not be dismissed that adoption of a lower BP target may increase the number of patients that at least achieve the higher one. Adopting lower BP targets for strategic rather than for scientific reasons will only be justifiable; however, if one can exclude that at lower BP targets the beneficial effects of treatment, although not enhanced, are not attenuated, with, thus, an exposure of the patients to a J-curve phenomenon [10]. As mentioned by the 2013 ESH/ESC guidelines [1], this remains a controversial issue of fundamental importance for public health which future research should regard as priorital.

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Conflicts of interest

There are no conflicts of interest.

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8. Mancia G, Schumacher H, Redon J, Verdecchia P, Schmieder R, Jennings G, et al. Blood pressure targets recommended by guidelines and incidence of cardiovascular and renal events in the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET). Circulation 2011; 124:1727–1736.
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