CARDIOVASCULAR PROTECTION IN HYPERTENSION. WHICH TARGETS FOR TREATMENT

A huge amount of evidence is available that antihypertensive treatment is accompanied by a reduction in the risk of cardiovascular (CV) and renal outcomes as well as that a major portion of the beneficial effect is due to blood pressure (BP) lowering per se, regardless how it is obtained. Despite decades of research, however, information is still not conclusive on which might be the BP values to achieve with treatment in order to maximize CV and renal protection. This presentation will address this issue by reviewing the current target BP values recommended by guidelines in the general and elderly hypertensive population with a description of the related evidence. It will then show the modifications that may be supported by recent meta-analyses of randomized trials as well as by post-hoc analysis of some large scale trials. It will finally focus on the results of the SPRINT trial that much lower BP target may increase the benefits at all ages., thereby challenging the conservative attitude of current guidelines. The point will be made that, although potentially very important the SPRINT trials presents with several aspects that are difficult to interpret, as well as with inconveniences (marked increases of serious side effects in the intensively treated patients) that in real life may favour discontinuation and low adherence to treatment with a resulting increase of CV risk that may attenuate, if not offset, any theoretical benefit. The conclusion will be drawn that further evidence on this issue is needed and that future trials should explore, in particular, possible differences in optimal BP target according to demographic characteristics (including ethnicity) and clinical phenotypes (presence or absence of organ damage, duration of disease, type of event protected, etc). Attention will be directed also on the need to establish optimal target also for out-of-office BP and other BP effects of treatment, such as long-term BP variability.