Keep Blood Pressure Low, but Not Too Much….

The recently released 2018 European Society of Cardiology/ European Society of Hypertension (ESC/ESH) Guidelines state that BP should be lowered to levels <140/90 mm Hg in all patients (class I, level of evidence A recommendation) and to ≤130/80 mm Hg in most patients provided that the treatment is well tolerated (I A recommendation). Thus, the take-home message of the 2018 ESC/ESH Guidelines is that a BP target <140/90 mm Hg is the first objective of treatment and that a more ambitious BP goal (≤130/80 mm Hg) should be pursued in most patients at condition that the treatment is well tolerated at levels <140/90 mm Hg. Unfortunately, to quote an aphorism attributed to Voltaire, “the perfect is enemy of the good.” Indeed, a few lines below, the European Guidelines complicate the message by adding the recommendation (I A) that systolic BP should be lowered to <140 mm Hg, but not to <130 mm Hg, in patients aged ≥65 years, a consistent proportion of hypertensive patients. The 2018 European Guidelines also add that the systolic BP target 130 to <140 mm Hg is recommended at any level of cardiovascular (CV) risk and in patients with and without established CV disease. Therefore, even patients with hypertension complicated by clinical conditions including stable chronic coronary artery disease, prior stroke, congestive heart failure, diabetes mellitus, and kidney failure should not have their systolic BP reduced <130 mm Hg if the age of patient is ≥65 years. Such recommendation contrasts with the 2017 American College of Cardiology/American Heart Association Hypertension Guidelines, approved by other 9 US Scientific Societies, which recommend a systolic BP target <130 mm Hg in almost all hypertensive patients. In plain words, hypertensive patients aged ≥65 years should not have their systolic BP lowered <130 mm Hg in Europe, whereas it is recommended to lower their systolic BP <130 mm Hg in the United States. Ironically, one could argue that, on one side of the Ocean, someone may have misinterpreted the evidence supporting the Hypertension Guidelines. When looking at younger patients, that is, those aged <65 years, the 2018 European Guidelines state that systolic BP should be lowered to <130 mm Hg in most patients, but not <120 mm Hg (I A recommendation). Specifically, the guidelines first recommend of being more aggressive with judicio (ie, taking patient’s tolerability, as assessed during the clinical visit, into account). Subsequently, however, the guidelines introduce a sort of formal own judicio consisting of precise safety boundaries not to be exceeded (120 mm Hg in patients aged <65 years, 130 mm Hg in patients aged ≥65 years). Thus, 31 years after the first report by Cruickshank et al, the 2018 ESC/ESH Guidelines seem to fully endorse, with the strength of a I A recommendation, the implication of the J-curve hypothesis. Namely, an excessive reduction in BP should be avoided because it may expose patients to added risk instead of benefit. There are abundant pros and cons reports in the literature on the J-curve hypothesis. The European Guidelines cite, to support the statement that the risk of harm appears to increase and outweigh the benefits when systolic BP is lowered to <120 mm Hg, a post hoc analysis by Böhm et al of the ONTARGET trial (Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial) and TRANSCEND trial (Telmisartan Randomised Assessment Study in ACE Intolerant Participants With Cardiovascular Disease). The ONTARGET and TRANSCEND trials have been conducted in patients aged ≥55 years without symptomatic heart failure at entry and with a history of chronic coronary artery disease, peripheral artery disease, transient ischemic attack, stroke, or diabetes mellitus complicated by organ damage. Patients were recruited in 40 countries and followed up for a median of 56 months. Notably, about 30% of these patients did not have a positive history of hypertension. In analysis by Böhm et al, mean achieved systolic BP values <120 mm Hg during treatment were not associated with an increased risk of myocardial infarction or stroke, but were related to a higher risk of all-cause mortality and CV mortality and heart failure, which guided the composite The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the Fondazione Umbra Cuore e Ipertensione-ONLUS e Struttura Complessa di Cardiologia (P.V., C.C.) and Struttura Complessa di Cardiologia e Fisiopatologia Cardiovascolare (F.A.), Ospedale S. Maria della Misericordia, Perugia, Italy; and Dipartimento di Medicina, Università di Perugia, Italy (G.R.). Correspondence to Paolo Verdecchia, FESC, FACC, Fondazione Umbra Cuore e Ipertensione-Organizzazione Non Lucrativa di Utilità Sociale (ONLUS), Ospedale S. Maria della Misericordia, 06129-Perugia, Italy. Email verdec@tin.it Viewpoints