Maximizing Cardiovascular Event Reduction by Expanding and Intensifying the Targets
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Article, see p 798
Hypertension is a leading risk factor for death and disability-associated life years in the United States.1 The US prevalence of hypertension using a conventional definition of hypertension, systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, is at epidemic proportions and continues to increase alongside the prevalence of modifiable lifestyle factors for high blood pressure, such as physical inactivity, high-sodium diets, obesity, tobacco use, and alcohol use.2 Despite our tremendous scientific understanding of the cardiovascular risk factors that predispose to adverse health outcomes, pinpointing the blood pressure for optimal risk reduction continues to evolve and be debated. Although it has been well established that a linear relationship exists between elevations in systolic blood pressures >110 to 115 mm Hg and cardiovascular events in every age group,3 most blood pressure guidelines have focused on blood pressure-lowering treatment in those patients meeting conventional hypertension definitions. National and international blood pressure awareness, treatment, and control campaigns have been aimed exclusively at patients with blood pressure ≥140/90 mm Hg. By targeting such patients, where it was commonly perceived that the majority of cardiovascular events were occurring, it was hoped that the majority of preventable cardiovascular events could be most effectively addressed. Yet taking a more expansive view beyond which patients are at highest risk to one that accounts for which patients constitute the majority of cardiovascular events, a different perspective emerges. For the entire population, ≈450 000 Americans die each year from cardiovascular diseases secondary to chronic elevations in systolic blood pressure >110 to 115 mm Hg, with many cardiovascular events occurring in individuals with blood pressures above optimal but below conventional hypertension definition.1,4
The recent landmark SPRINT (Systolic Blood Pressure Intervention Trial) provided strong evidence that the undertreatment of high blood pressure for patients with …