Hypertension is a leading risk factor for cardiovascular disease, the leading cause
of death and morbidity in our society and on a global scale. Major components of cardiovascular
disease include stroke, coronary artery disease, heart failure, and chronic kidney
disease, in all of which hypertension plays a major role. The risk of these complications
increases directly and linearly with systolic blood pressure starting at 115 mmHg.
Although usually asymptomatic, hypertension is readily detectable on physical examination
and is amenable to both lifestyle modification and pharmacologic treatment in most
patients. However, large proportions of the hypertensive population remain undetected
and undertreated. Numerous guidelines have been issued during the past few decades
to promote detection and optimal therapy. Despite the increase in risk with systolic
blood pressure greater than 115 mmHg, the generally accepted threshold for diagnosis
and treatment has been systolic blood pressure greater than 139 mmHg and diastolic
blood pressure greater than 80 mmHg because until recently treatment to lower levels
has been associated with an unfavorable relation between clinical benefit and harm.
In the past several years, new guidelines, advisories, commentaries, and clinical
trials have provided evidence for a potential change in current recommendations for
the management of hypertension. In this regard, the long-awaited eighth report of
the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure recommended patients older than 60 years be treated to a systolic
blood pressure of less than 150 mmHg, which has generated considerable controversy
and caution. The striking findings of the Systolic Blood Pressure Intervention Trial
(SPRINT) have received considerable attention because of the demonstration that intensive
therapy to a target systolic blood pressure below 120 mmHg decreases cardiovascular
mortality and morbidity more than less intensive treatment to a target systolic blood
pressure below 140 mmHg, but this approach is not fully generalizable because the
trial excluded patients younger than 50 years and those with diabetes and prior stroke.
This article addresses major issues in the management of hypertension, including those
in the seventh and eight reports of the Joint National Committee on the Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure and subsequent studies,
considering maintenance of prior standards as well as the potential application of
important new findings.