Misleading guidelines for the diagnosis and management of hypertension

ABSTRACT

The new international guidelines for the diagnosis and management of hypertension proposed higher thresholds for the diagnosis of hypertension in patients with higher cardiovascular risk, such as patients with diabetes, chronic kidney disease, and the elderly. The premise for the new recommendations was the results of randomized clinical trials, such as the ACCORD trial. Nonetheless, the results of the ACCORD trial were within the predicted by the meta-analysis of risk and confirmed by metaanalysis of clinical trials, particularly for stroke. The decision to use 140 mmHg as the therapy goal would be to deny diabetic patients the benefit of preventing a large proportion of strokes. In addition, the meta-analysis conducted in the United States did not address prehypertension, ignoring many trials performed with patients presenting prehypertension and cardiovascular disease, showing the benefit of further lowering blood pressure. The guidelines recommended angiotensin receptor blockers as one of the first options for all patients and particularly patients with diabetes and chronic kidney disease. Three recently published meta-analyses and review showed that these agents are practically inert in the prevention of allcause death and cardiovascular events. In conclusion, there is evidence showing that hypertension should be more aggressively prevented and treated, and that angiotensin receptor blockers should not be the first option to start the treatment.