Correspondence to Paolo Verdecchia, FESC, FACC, Fondazione Umbra Cuore e Ipertensione-Organizzazione no Lucrativa di Utilità Sociale (ONLUS), Ospedale S. Maria della Misericordia, 06129-Perugia, Italy. Email E-mail Address:

From the Fondazione Umbra Cuore e Ipertensione-ONLUS e Struttura Complessa di Cardiologia (P.V., C.C.), Ospedale S. Maria della Misericordia, Perugia, Italy


Fabio Angeli

Struttura Complessa di Cardiologia e Fisiopatologia Cardiovascolare (F.A.), Ospedale S. Maria della Misericordia, Perugia, Italy


Claudio Cavallini

From the Fondazione Umbra Cuore e Ipertensione-ONLUS e Struttura Complessa di Cardiologia (P.V., C.C.), Ospedale S. Maria della Misericordia, Perugia, Italy


Originally published8 Nov 2018https://doi.org/10.1161/CIRCRESAHA.118.314017Circulation Research. 2018;123:1205–1207

If a male will start with certainties, he shall end in doubts; but if he will be contents to start with doubts, the shall finish in certainties.

You are watching: Blood pressure 118/68

—Francis Bacon, The development of Learning. Holborne. 1605


To what extent should blood pressure (BP) be lowered in hypertensive patients? need to ≥1 BP targets it is in strictly defined? Or need to we keep going the goal to individual patients, considering determinants such together age, comorbidities, and also balancing efficacy and also tolerability that treatment?

The freshly released 2018 European culture of Cardiology/European society of Hypertension (ESC/ESH) guidelines state the BP should be lowered to level 1

Thus, the take-home post of the 2018 ESC/ESH guidelines is the a BP target 1

Unfortunately, come quote an aphorism attributed to Voltaire, “the perfect is foe of the good.” Indeed, a couple of lines below, the europe Guidelines1 complicated the article by including the referral (I A) the systolic BP should be lower to 2

In level words, hypertensive patients aged ≥65 years must not have actually their systolic BP lower 1

Specifically, the guidelines an initial recommend that being much more aggressive with judicio (ie, taking patient’s tolerability, together assessed during the clinical visit, into account). Subsequently, however, the guidelines introduce a sort of formal very own judicio consisting of an accurate safety boundaries not come be gone beyond (120 mm Hg in patients age 1 Thus, 31 year after the an initial report by Cruickshank et al,3 the 2018 ESC/ESH Guidelines it seems to be ~ to fully endorse, with the toughness of a i A recommendation, the implicitly of the J-curve hypothesis. Namely, an too much reduction in BP need to be avoided because it may expose patient to added risk rather of benefit.

There are plentiful pros and cons reports in the literary works on the J-curve hypothesis.3–7 The europe Guidelines cite, to assistance the statement the the risk of harm appears to increase and outweigh the benefits once systolic BP is lowered to 8 that the ONTARGET trial (Ongoing Telmisartan Alone and in combination With Ramipril worldwide End suggest Trial) and TRANSCEND psychological (Telmisartan Randomised Assessment examine in ACE Intolerant Participants with Cardiovascular Disease). The ONTARGET and TRANSCEND trials have been performed in patients age ≥55 years without symptomatic heart fail at entry and also with a history of chronic coronary artery disease, peripheral artery disease, transient ischemic attack, stroke, or diabetes mellitus facility by body organ damage. Patients were recruited in 40 countries and followed up because that a median of 56 months. Notably, around 30% of these patients walk not have actually a positive history of hypertension. In evaluation by Böhm et al,8 mean accomplished systolic BP worths 8 by no method shows that achieved BP worths 65 years disclose an boosted risk.

The discrepancy in between the lack of J-curve impact on myocardial infarction and also stroke and the impact on mortality raise the opportunity of reverse causality as potential contributory to results. Indeed, there is ample evidence that, independent of antihypertensive treatment, low systolic BP values room strongly connected with an excess hazard of mortality in the last years of life in patients v heart failure, renal failure, and in the general population with and also without frailty.9,10 Thus, nonrandomized epidemiological associations linking short systolic BP with higher mortality need to be interpreted cautiously since of the likelihood of turning back causality, particularly if the short BP worths are taped a few months or years prior to death. Correctly, Böhm et al8 concluded the it is not feasible to dominance out some result of reverse causality in explaining your results.

Interestingly, the study by Böhm et al8 confirms a previous analysis by our group of the exact same ONTARGET/TRANSCEND database, limited to patients through coronary artery disease at entrance (ie, one ideal population to test the J-curve hypothesis due to the fact that an excessive reduction in diastolic BP could theoretically cause coronary hypoperfusion in the visibility of far-reaching stenosis). After ~ adjustment for several potential components of reverse causality including cancer and heart failure, which entered the analysis as time-varying covariables, a palliation in BP indigenous baseline by 34/21 mm Hg, matching to an completed BP of just 118/68 mm Hg, was connected with a markedly diminished risk the stroke, there is no any significant increase in the risk of myocardial infarction (Figure).4

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The strong (I A) recommendation of ESC/ESH Guidelines1 that systolic BP need to not be lower 11 a greater reduction in systolic BP, was connected with a higher risk reduction v no evidence of a J-curve effect. In a network meta-analysis by Bundy et al,12 a mean accomplished systolic BP 120 come 124 mm Hg was associated with a far-ranging reduction in the threat of CV an illness and all-cause mortality even in the to compare with achieved systolic BP levels 125 come 129 mm Hg (hazard ratios the 0.82 (0.67–0.97) and also 0.74 (0.57–0.97), respectively). Bangalore et al,13 in a network meta-analysis consisting of trials designed to compare different BP targets, concluded that systolic BP targets 13

On balance, the proof accrued to day does not support the 2018 ESC/ESH Guidelines recommendation (I A recommendation) which formally specifies safety boundaries that should not be exceeded for the risk of increased injury out-weight the benefits.1

Recently, Messerli et al14 remarked a possible rift in between those who write the guidelines and those who treat the patients. By applying this ide to the 2018 ESC/ESH Hypertension Guidelines, how should we manage in the everyday practice ours patients v BP below the safety and security boundaries and perfect tolerability of treatment? follow to accuse would suggest that we need to discourage this patients to continue their medicine treatment, completely or in part, to lug BP above the safety and security BP boundaries. If not, there could be a theoretical risk because that a European doctor to be indicted, especially in situation of following complications, through the charge of noncompliance through the official ESC/ESH Guidelines for enduring a also low BP.

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To conclude, we think the there is robust evidence from randomized trials and meta-analyses that BP should be lower to reduced levels than assumed to date. Having said that, rather of addressing rigid BP targets or safety thresholds, what we need to pursue in day-to-day practice is the optimal balance between the size of completed BP reduction and also the tolerability of treatment in each single patient.15 components such together age and also comorbidities should be closely considered as soon as assessing this balance.15

In ours opinion, the 2018 european Guidelines i A recommendation that systolic BP should not it is in lowered below predefined safety boundaries (120 mm Hg in patients aged

The opinions express in this post are not necessarily those the the editors or the the American love Association.