Management of Hypertension based on blood pressure level versus an absolute cardiovascular risk approach

Purpose of Review: To address the tension between guideline recommendations and the evidence from clinical trials supporting them and clinician concerns of overtreatment of elevated blood pressure.

Recent Findings: Systolic Blood Pressure Intervention trial (SPRINT) demonstrated lower blood pressure targets provided robust clinical benefit (reduced all-cause mortality) but also expected adverse events due to hypotension. Treatment thresholds for systolic blood pressure in the latest US guidelines have been lowered to 130 mmHg, although this has not been adopted elsewhere. These guidelines specify that treatment in the 130 s should be considered in the setting of absolute risk, i.e. treatment should be directed to those at high risk. This review argues that this hybrid approach, treatment thresholds in the 130 s based on absolute risk and above 140 mmHg on blood pressure level alone is a compromise, and that risk stratification should be the basis of drug treatment decision-making unless blood pressure is very high. Who receives blood pressure lowering medication is best determined by who is most likely to have a heart attack or stroke in the intermediate period rather than medicalising individuals who have a mildly elevated blood pressure.