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HBP RECOMMANDATION 2007

HBP RECOMMANDATION 2007

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MISE AU POINT SUR LE TRAITEMENT DE L'HYPERTENSION ARTÉRIELLE; DU DIAGNOSTIC A LA PRISE EN CHARGE
MISE AU POINT SUR LE TRAITEMENT DE L'HYPERTENSION ARTÉRIELLE; DU DIAGNOSTIC A LA PRISE EN CHARGE

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Published by: lamcenter on May 05, 2008
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10/07/2012

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On the basis of current evidence it can be recommended
that blood pressure be lowered at least to below 140/
90 mmHg in all hypertensive patients and that lower
values be pursued if tolerated. Antihypertensive treatment
should be more aggressive in diabetics, in whom a target
blood pressure of ,130/80 mmHg appears a reasonable
one. Similar targets should be adopted in individuals with
a history of cerebrovascular disease and can at least be con-
sidered in patients with coronary disease. Although differ-
ences between individual patients may exist, the risk of

underperfusion of vital organs is very low, except in episodes
of postural hypotension that should be avoided, particularly
in the elderly and diabetic. The existence of a J-shaped
curve relating outcomes to achieved blood pressure has so
far been suspected as a result of post-hoc analyses486–490
which have reported, however, the rate of events to
increase at quite low diastolic pressures. Further evidence
that an inflection of the curve may only occur at blood
pressure levels much lower than those aimed at with
intense antihypertensive therapy is provided by randomized
studies in post-myocardial infarction or chronic heart failure
patients, in whom b-blockers or ACE inhibitors reduced the
incidence of cardiovascular events despite lowering blood
pressure from already quite low initial systolic and diastolic
values.482,491

It should be mentioned that, despite wide use of multi-
drug treatment, in most trials the achieved average systolic
blood pressure remained above 140 mmHg,492

and even in
trials achieving average blood pressure values , 140 mmHg,
the control rate included at most 60–70% of recruited
patients. In diabetic subjects average on-treatment values

, 130 mmHg were never obtained,492

except in the ABCD
normotensive trial that recruited subjects with initially
normal or high normal blood pressures.319

Reaching the
target blood pressures recommended above may thus
be difficult and the difficulty may be greater when initial
blood pressures are higher and in the elderly since age
makes the elevation in systolic blood pressure strictly
dependent on increased aortic fibrosis and stiffness. Trial evi-
dence also shows that for the same or even a greater use of
combination treatment achieved systolic blood pressure
remains usually somewhat higher in diabetics than in
non-diabetics.249,428,493

5.3 Cost-effectiveness of antihypertensive
treatment

Several studies have shown that in high or very high risk
patients, treatment of hypertension is largely cost effective,
that is that the reduction in the incidence of cardiovascular
disease and death largely offsets the cost of treatment
despite its lifetime duration.494

Indeed, it is likely that the
benefit is even greater than that calculated by the number
of events saved per year of treatment and expressed by
the so called number needed to treat or ‘NNT’.495

1) In
several placebo-controlled trials a substantial number of
patients randomized to placebo received treatment and a
number of patients allocated to active treatment actually
withdrew from it while continuing to be considered in the
original groups according to the intention-to-treat prin-
ciple;273

2) Some trials show that the difference in event
incidence between treated and placebo groups increases
progressively over the few years of the trial duration,
raising the possibility of a greater long-term protective
effect of blood pressure reductions; 3) In younger low risk
hypertensives what appears to be as a relatively small
benefit when calculated over a treatment period of 5
years may translate into a more substantial number of
added life years compared with elderly high risk hyperten-
sives.274

This implies that in younger subjects actuarial
information may provide a better assessment of the
benefit than data obtained in trials.496

In young patients
the purpose of treatment is not to prevent an unlikely

ESC and ESH Guidelines

1489

morbid or fatal event in the subsequent few years, but
rather to prevent onset and/or progression of organ
damage that will, in the long term, convert the low risk
patient into a higher risk one. Several trials of antihyperten-
sive therapy, foremost the HDFP312

and HOT497

studies, have
shown that despite intense blood pressure lowering the inci-
dence of cardiovascular events remains much higher in high
risk hypertensives or hypertensives with complications than
in hypertensives with initial low or moderate risk. This
suggests that some of the major cardiovascular risk
changes may be difficult to reverse, and that restricting
antihypertensive therapy to patients at high or very high
risk may be far from an optimal strategy. Finally, the cost
of drug treatment of hypertension is often contrasted to
lifestyle measures, which are considered cost-free.
However, real implementation, and therefore effectiveness,
oflifestylechangesrequiresbehaviouralsupport,counselling
and reinforcement, the cost of which may not be
negligible.498,499

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