Whom to Treat for High Blood Pressure—Time for a Precision Approach

For decades, the threshold blood pressure (BP) values of 140 mm Hg or higher systolic BP or 90 mm Hg or higher diastolic BP at more than 1 encounter have defined the diagnosis of hypertension for most patients. The 2017 American Heart Association/American College of Cardiology (AHA/ACC) hypertension treatment guidelines set lower treatment goals of 130 mm Hg systolic BP and 80 mm Hg diastolic BP for high cardiovascular risk patients.¹ While threshold BPs simplify treatment decisions, a preponderance of observational evidence has established a continuous, log-linear relationship between BP and risk for cardiovascular disease events, at least down to systolic BPs in the range of 115 to 120 mm Hg and diastolic BP around 75 mm Hg. The question for clinical practice is whether BP treatment goals should be guided by this evidence, favoring ever-lower BPs until adverse event risks or treatment costs overwhelm expected benefits?