2 Simplified BP Targets vs. the ‘Lower the Better’ The achieved level of SBP and DBP control is directly associated with the risk of cardiovascular (CV) disease (CVD) and stroke, across patient ages and ethnicities [9, 10]. Reducing the incidence of mortality and morbidity associated with CVD is linked to substantial socioeconomic and healthcare cost
savings [11]. Therefore, should BP targets be more aggressive than suggested in the latest 2013 ESH/ESC guidelines? The 2013 ESH/ESC recommendation for a BP target of <140/90 mmHg for most patients is based on a review of randomized controlled trial (RCT) data [12] that suggested a lack of evidence for a PLX4032 more aggressive, and previously recommended, BP target of <130/80 mmHg in patients with high CV risk [2]. However, the authors of the review state that despite scant evidence for lowering SBP below 130 mmHg in patients with diabetes or high/very high CV risk, a more aggressive approach may be prudent because antihypertensive therapy to
lower SBP to <130 mmHg appears well tolerated; they suggest more solid trial evidence should be gained [12]. Despite many major trials not achieving BP targets of <140/90 mmHg, there is a wealth of evidence to indicate a relationship between lower BP and reduced CV outcomes, suggesting further benefits are available from greater BP reductions. Certainly, in low-to-moderate risk patients https://www.selleckchem.com/products/Fulvestrant.html with uncomplicated hypertension, trial evidence supports that a reduction in SBP to <140 vs. >140 mmHg is associated with reduced adverse CV outcomes [13–15]. Other supportive evidence for intensive BP lowering in a range of patients is available, showing a lower risk of major CV events, especially stroke [16, 17] (Table 1). Law et al. performed a meta-analysis of data from randomized trials of BP-lowering therapy involving almost Thymidylate synthase half a million patients (with and without CVD), and observed substantial reductions in heart disease and stroke for a 10-mmHg reduction in SBP or a 5-mmHg reduction
in DBP, down to 110/70 mmHg [6]. A further meta-analysis of 32 randomized trials showed that reduction of SBP to 126 vs. 131 mmHg had the same proportional CV benefits as a reduction to 140 vs. 145 mmHg [18]. The Heart Outcomes Prevention Evaluation (HOPE) study demonstrated significant reductions in the risk of a composite outcome of CV mortality, myocardial infarction (MI), and stroke following antihypertensive treatment down to a SBP of 134 mmHg [19]. Additionally, the Perindopril pROtection aGainst REcurrent Stroke Study (PROGRESS) trial (in patients with a history of stroke) revealed that the lowest follow-up BP levels (median 112/72 mmHg) were associated with the lowest risk of stroke recurrence, with progressively increased risk at higher BP levels [20].