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Antihypertensive Treatment and Blood Pressure in Diabetic and Nondiabetic Patients

The lower, the better?

  1. Alberto Zanchetti, MD2
  1. 1Clinica Medica, Dipartimento di Medicina Clinica e Prevenzione, Università Milano-Bicocca, Ospedale San Gerardo, Monza (Milan), Italy
  2. 2Istituto Auxologico Italiano, Milan, Italy
  1. Corresponding author: Giuseppe Mancia, giuseppe.mancia@unimib.it.

International guidelines on hypertension recommend maintaining blood pressure (BP) below 140 mmHg systolic and 90 mmHg diastolic in the general hypertensive population up to the age of 80 years. A more aggressive BP target is recommended when the hypertensive patient has an additional risk for cardiovascular disease, such as if the patient has diabetes, renal disease, or a prior history of cardiovascular disease. In these situations, guidelines encourage decreasing BP below 130/80 mmHg to grant additional cardiovascular protection (13).

In the last 2 years, the target BP values recommended by guidelines have been the object of some dissenting views (4,5), based on the argument that these targets are often not supported by evidence from prospective randomized trials (4) and that lowering BP too aggressively may do harm rather than ensuring protection. This article addresses this issue by examining three sets of relevant studies: randomized trials, post hoc analysis of prospective studies, and studies on organ damage. Because of space limitations, the References do not include all single trials mentioned; the reader can refer to a recent document of the European Society of Hypertension for this information (5). This is the case also for the acronym of the trials quoted in Fig. 1.

RANDOMIZED TRIALS

As shown in Fig. 1 (4,5), there is little question that the target BP values recommended by guidelines are not consistently based on trials that compared an actively treated group with placebo or patients treated with less aggressive target BP. To-date trial evidence supports the recommendation to lower systolic BP below 140 mmHg in grade I uncomplicated low cardiovascular risk hypertensive patients, based on the fact that in most trials that involved these patients (although often their “uncomplicated low-risk hypertension category” was questionable [4]), a reduction in cardiovascular …

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