Preventing Vascular Events Due to Elevated Blood Pressure

Elevated blood pressure (BP) demonstrates a consistent, strong, and graded relationship across the entire spectrum at levels >110 mm Hg systolic with several cardiovascular disease outcomes including cardiovascular death, myocardial infarction (MI), stroke, heart failure, and renal dysfunction.1 The population attributable risk due to elevated BP is large and consistent in all ethnic groups and regions of the world.2,3 In many countries (eg, United States, Canada, and Japan), strokes (especially hemorrhagic strokes) have been declining, which can be attributed, to a significant extent, to better BP control, although other factors (eg, changing diets and social and economic circumstances) are also likely to be important.4 By contrast, over the last 2 or 3 decades, the prevalence of heart failure has been increasing5 despite the increase in the proportion of patients with hypertension receiving BP-lowering therapy. This overall picture masks a decrease in heart failure in younger individuals, which is more than counterbalanced by an increase in the elderly.5Article p 2201 Undoubtedly, BP lowering reduces heart failure to a substantial degree, but the randomized trials that have generated this evidence have generally lasted usually for an average of 5 years.6 At first glance, a 5-year trial may seem to be of long duration, but in fact it represents a relatively short duration of treatment (because the average time of treatment in these trials before an event occurs is approximately half the duration of the trial, which is only &2.5 years) compared with the need for lifelong therapy over several decades. Over this period, BP control often gets poorer as patients get older, long-term adherence to antihypertensive therapy declines, and new cardiovascular events (eg, a heart attack or renal dysfunction) or noncardiovascular events (eg, arthritis) develop, which either directly or indirectly (eg, through the use of …