Hypertension: a global health issue
High blood pressure, or hypertension, is a major risk factor for cardiovascular disease, stroke, and kidney failure. Over the past few decades, the treatment of hypertension has undergone numerous updates, with guidelines that have progressively refined therapeutic recommendations. Recently, new international guidelines have reduced the target of blood pressure treatment, lowering the optimal levels to be achieved in hypertensive patients. This change has raised significant discussions among health professionals, regarding both the benefits and potential risks associated with more intensive treatment.
Hypertension is a common condition, affecting approximately 30-45% of the adult population globally, with higher prevalences in older people. According to the World Health Organization (WHO), hypertension is responsible for approximately 7.5 million deaths each year, accounting for 12.8% of all deaths worldwide. Hypertension is more common in low- and middle-income countries, but it is also a major cause of morbidity and mortality in high-income countries. If left untreated, hypertension can lead to serious complications such as cardiovascular disease (myocardial infarction, heart failure), stroke, chronic kidney disease, and retinopathy.
Risk factors for hypertension include older age, genetic predisposition, obesity, a diet high in sodium and low in potassium, physical inactivity, excessive alcohol consumption, and chronic stress. Hypertension is the result of a complex interaction between genetic, environmental, and behavioral factors that lead to increased peripheral vascular resistance and elevated pressure on the arterial walls. This can lead to endothelial damage, arterial stiffness, and cardiac dysfunction. In this article, we explore the new guidelines, review the scientific evidence that led to this update, and discuss the clinical and practical implications of these changes.
New Guidelines for the Treatment of Hypertension
Reduction of the Therapeutic Target
The new guidelines for the management of hypertension, published by several international organizations including the American College of Cardiology (ACC) and the American Heart Association (AHA), have reduced the therapeutic target for blood pressure, lowering the optimal level of treatment to less than 130/80 mmHg from the previous standard of 140/90 mmHg.
- Previous Target: Previously, treatment of hypertension aimed to reduce blood pressure below 140/90 mmHg for most patients, with a slightly higher target for older adults.
- New Target: The new guidelines recommend reducing blood pressure below 130/80 mmHg for all patients, regardless of age, with a more aggressive approach to managing hypertension.
Supporting scientific evidence
The change in guidelines is based on a strong body of scientific evidence, particularly the results of the Systolic Blood Pressure Intervention Trial (SPRINT), one of the largest and most rigorous clinical trials in hypertension.
- SPRINT study: The SPRINT study demonstrated that reducing systolic blood pressure to a target of less than 120 mmHg, compared with the standard target of less than 140 mmHg, significantly reduces the risk of major cardiovascular events, stroke, and all-cause mortality. However, the target of 130/80 mmHg represents a trade-off between the observed benefits and the reduction in risks associated with overly intensive treatment.
- Meta-analyses and systematic reviews: Further meta-analyses and systematic reviews have confirmed that tighter blood pressure control is associated with a reduction in the risk of cardiovascular complications, without a significant increase in side effects.
Benefits of Intensive Treatment
Reducing the therapeutic target offers numerous benefits for hypertensive patients, contributing to more effective management of the disease and prevention of long-term complications.
- Reduction of cardiovascular risk: Tighter blood pressure control reduces the risk of myocardial infarction, heart failure and death from cardiovascular causes.
- Prevention of stroke: Reduction of blood pressure is one of the most important factors in the prevention of stroke, with a significant impact on mortality and long-term disability.
- Protection of renal function: Aggressive management of hypertension helps prevent the progression of chronic kidney disease, reducing the risk of needing dialysis or kidney transplantation.
Risks Associated with Intensive Treatment
Despite the benefits, intensive treatment of hypertension may carry some risks, which must be carefully balanced against the potential benefits.
- Cerebral hypoperfusion: Excessively reducing blood pressure, especially in elderly patients or those with vascular disease, may increase the risk of cerebral hypoperfusion, causing dizziness, confusion, and an increased risk of falls.
- Drug side effects: Increasing the number and dosage of antihypertensive medications needed to reach the new target may lead to increased side effects, such as orthostatic hypotension, renal dysfunction, and electrolyte imbalances.
- Treatment adherence: The more intensive treatment regimen may place a greater burden on patients, affecting long-term adherence to treatment. The polypharmacy required to reach the new targets may be complex and require more frequent monitoring.
Implementation in clinical practice
The adoption of the new guidelines requires significant adaptation in clinical practice, with particular attention to tailoring treatment to individual patients.
- Personalized Approach: Despite the new recommendations, it is essential to tailor treatment based on individual patient characteristics, considering factors such as age, comorbidities and drug tolerance.
- Patient Education: Patients should be informed about the benefits and risks associated with intensive treatment, and actively involved in the decision-making process regarding the management of their blood pressure.
- Monitoring and Follow-Up: Regular monitoring of blood pressure and metabolic parameters is crucial to avoid side effects and ensure long-term treatment efficacy.
Public health implications
Implementation of the new guidelines could have a significant impact on public health, helping to reduce the burden of cardiovascular disease and improving the quality of life of people with hypertension. By narrowing the treatment target, a greater number of cardiovascular events could be prevented, reducing the need for more expensive and invasive interventions later on. Adopting educational and support strategies to improve adherence to treatment could amplify the benefits of the new guidelines, leading to greater blood pressure control in the general population. The new guidelines should be integrated into public health programs and awareness campaigns, to promote blood pressure control and reduce the risk of complications at the population level.
Global challenges
Adopting the new guidelines globally poses several challenges, especially in low- and middle-income countries, where access to medicines and care is often limited.
- Accessibility to medications: Implementing intensive treatment requires access to a wide range of antihypertensive medications, which can be a significant challenge in resource-limited settings.
- Education of healthcare professionals: Investments in education of healthcare professionals are needed to ensure they are up-to-date on the new guidelines and able to effectively implement them in clinical practice.
- Health equity: Disparities in access to care may widen inequalities in hypertension management. Global efforts should focus on adopting strategies that ensure equitable and effective treatment for all patients.
Conclusions
The new guidelines for the management of hypertension, with a reduced therapeutic target, represent an important evolution in the prevention and treatment of cardiovascular disease. Although lowering the target offers significant benefits in terms of reducing cardiovascular risk, it is essential to carefully consider the potential risks and personalize treatment for each patient. Effective implementation of the new recommendations requires a multidisciplinary approach that includes patient education, regular monitoring, and strict adherence to therapies. With proper planning and the adoption of supportive strategies, the new guidelines could significantly contribute to improving cardiovascular health globally, reducing the burden of diseases associated with hypertension and improving the quality of life of people affected by this condition.
- Edited by Dr. Gianfrancesco Cormaci, PhD, specialist in Clinical Biochemistry.
Scientific references
Whelton PK et al. (2018). J Amer College Cardiol, 71(19), e127-e248.
SPRINT Research Group. (2015). New Engl J Medicine, 373(22), 2103.
Ettehad D, Emdin A et al. (2016). The Lancet, 387(10022), 957-967.
Williams B et al. (2018). European Heart Journal, 39(33), 3021-3104.
Muntner P, Carey RM et al. (2018). J Amer College Cardiol 71(2), 109.
Bundy JD, He J. (2016). Annals of Global Health, 82(2), 227-233.