Main Issues for Achieving Blood Pressure Goals

It is well recognized that blood pressure (BP) control is below the goals recommended by guidelines. ¹ , ² In clinical practice, control rates above 30% (for a goal of <140/90 mm Hg) are uncommon. ³ Control rates above 40% have been described in hospital‐based hypertension units, ⁴ and control rates as high as 60% or more have been achieved in some clinical trials like ALLHAT. ⁵ If a goal lower than 130/80 mm Hg is considered as recommended in diabetes and chronic kidney disease, control rates are only 20%–30%. ⁴ These facts have led to the conclusion that BP goal attainment is difficult, especially for systolic BP. This has led some to believe that BP guidelines considered adequate could be elusive targets in daily clinical practice. ⁶

The first issue might be to define the threshold BP to start pharmacologic intervention, to slow down the progression of arterial hypertension, and reduce the progression of cardiovascular (CV) disease. Pharmacologic intervention, accompanied by lifestyle changes, is suggested if BP levels are above the limit defining stage 2 in arterial hypertension (>160/100 mm Hg). In the remaining cases, threshold BP is defined by the persistence of BP values above 140/90 mm Hg after a period of adequately performed lifestyle changes. Both the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and the European Society of Hypertension‐European Society of Cardiology (ESH‐ESC) guidelines ¹ , ² recognize the existence of compelling indications that suggest starting treatment even when BP levels are in the range of prehypertension. This is the case when target organ damage or associated clinical conditions are present. However, in daily clinical practice, the threshold BP to start pharmacologic therapy differs, and intervention frequently takes place when BP levels are clearly above the levels recommended by guidelines.

A second issue is how to initiate pharmacologic therapy, including which monotherapy to use and when to use combination therapy. An apparent discrepancy for the choice of the first drug exists between JNC 7 ¹ and the ESH‐ESC ² guidelines. JNC 7 recommends use of diuretics in most people as initial therapy to achieve a significant reduction in the risk that accompanies elevated BP at the lowest cost. On the contrary, the ESH‐ESC guideline recognizes the need for individual therapy, admitting that any drug available can be considered as adequate initial therapy. The demonstration that arterial hypertension is the number one risk factor in promoting death in developed as well as in developing countries ⁷ fits well with the concept of JNC 7; however, the fact that prehypertension may correlate well with insulin resistance⁸ forces the consideration that the benefit of simply lowering BP may not be enough to correct the risk of elevated BP. In fact, targeting prediabetes in hypertensive patients has been suggested ⁹ because it represents a situation frequently seen in clinical practice, in which the choice of an antihypertensive drug is relevant to promote, prevent, or retard the development of diabetes.

It is also true that the discussion of which monotherapy may be moot if we consider the large number of patients who require combination therapy to achieve adequate BP control. Only 22%–24% of people in clinical trials actually achieve blood pressure goals with monotherapy. The possibility of using a combination, either free or fixed, from the beginning of pharmacologic therapy in hypertensive patients is addressed in both guidelines. ¹ , ²

Implementing this approach will probably improve BP control.

A third relevant issue is the identification of predictors of a poor response to antihypertensive therapy. Several of these are related to poor lifestyles, especially related to diets containing an excessive amount of salt, an excessive number of calories facilitating an increase in body weight, an excess in alcohol intake, or a low intake of fruit and vegetables. Other factors are related to inadequate doses of antihypertensive drugs, inadequate combinations, or accompanying therapies interfering with antihypertensive therapy. Another important predictor of the need of multiple antihypertensive therapy is the degree of CV and renal involvement. The presence of associated clinical conditions or advanced target organ damage predicts more difficult control of BP and the need for more antihypertensive medication. ¹⁰ Moreover, it should be reemphasized that many patients do not take their prescribed medications. In most surveys, one quarter to one half of patients had abandoned antihypertensive drugs 1 year after starting therapy. ¹¹ It is also true that many physicians do not prescribe the appropriate medications required to control BP. ¹² The reasons for poor compliance and poor long‐term adherence are diverse, but poor tolerability to therapy has been noted as one of the most important. Recommendations directed to improve maintenance of antihypertensive therapy include appropriate educational programs for patients and appropriate prescriptions. ¹³ Importantly, physician inertia and failure to titrate medications until goal BPs are achieved is another major cause of poor control. ¹⁴

CV and renal disease have been described as a continuum, ¹⁵ starting with the detection of CV and renal risk factors, followed by the detection of target organ damage, and finally by associated clinical conditions. A fourth issue would be when to initiate pharmacologic and nonpharmacologic intervention. It is clear that lifestyle interventions can delay development of hypertension as well as reduce CV risk. It is not a matter only for physicians and health care professionals to discuss such issues. Public health authorities need to intervene and set up an economic system that reinforces health behavior and the early use of antihypertensive therapy, when necessary. ¹⁶