Importance of Rapid and Effective Reduction of Blood Pressure in Treating Hypertension for the Prevention of Cardiovascular Diseases : A Lesson from the VALUE Study.
The efficacy of antihypertensive medications in reducing the high blood pressure (BP) levels in patients with hypertension has been demonstrated, but the incidence of cardiovascular diseases in treated hypertensive subjects is still higher compared with subjects with normal BP values. This discrepancy could chiefly stem from: (a) the inability of the pharmacological treatment to normalise BP levels in all treated patients; (b) poor pre-evaluation of cerebral, cardiac and renal damage involvement in treated patients; and (c) the inappropriate choice of antihypertensive drug. If we consider that the recent guidelines on the treatment of hypertension have further reduced the thresholds of normal BP values (e.g. 120-129mm Hg for systolic and 80-84mm Hg for diastolic BP), we can hypothesise that in Italy today optimal control of BP in patients with hypertension could be further reduced, when compared with the past, and could be estimated to be obtained at present in only 25% of treated patients. This situation is of course unacceptable and efforts should be made by educational institutions to recommend that physicians apply current recommendations from the guidelines, aiming at properly normalising BP in treated hypertensive patients.The BP Treatment Trialists' collaboration study demonstrated that in treated hypertensive patients the extent of BP reduction by different drugs between randomised groups is closely associated with a reduction in cardiovascular risk. Recently the results from the VALUE (Valsartan Antihypertensive Long-term Use Evaluation) study showed that in treated hypertensive patients who are 'at high risk to develop cardiovascular events' even a small reduction of 3-4mm Hg in systolic BP, obtained immediately after starting therapy, could have a great impact on reducing the risk of developing cardiovascular diseases, such as myocardial infarction and stroke. In this trial, in the group of patients treated with a therapeutic regimen based on a calcium antagonist (amlodipine), there was significantly better control of BP values, resulting in a significant decrease in cardiovascular total events, compared with the group treated with a regimen based on an angiotensin II receptor blocking agent (valsartan).The key message of the VALUE study is that the reduction in BP, especially in high-risk patients, is more important than the mechanisms of action of the antihypertensive drugs, and that normalisation of BP may reduce the incidence of cardiovascular events. With regard to this latter point, it is evident how in future we cannot be satisfied with treatment of hypertensive patients until normalisation of BP is obtained, and normal BP levels should be reached as quickly as possible in the general population.
Department of Medicine, Emergency Medicine, University 'La Sapienza', Sant'Andrea Hospital, Via di Grottarossa 1035-1039, Rome, 00189, Italy, salvatore.disomma@uniroma1.it.
Salvatore
S
Di Somma