Treatment of high-risk hypertensive patients: Unresolved issues revised by staging the risk

Cardiovascular disease represents the leading cause of morbidity and mortality in Western countries, and hypertension-related cardiovascular events affect about 37 million people per year, worldwide. In this perspective, hypertension represents a reference paradigm to illustrate strategies aimed at achieving cardiovascular prevention. Hypertensive patients are at increased risk of experiencing a cardiovascular event during their life-time, and treatment of high blood pressure represents one of the most effective strategies to reduce the global cardiovascular risk of these patients. However, owing to its multifactorial pathophysiology and its frequent association with other relevant risk factors and clinical conditions, such as dyslipidaemia, diabetes mellitus, left ventricular dysfunction and renal impairment, hypertension requires an integrated approach to treatment, including life-style measures, antihypertensive drugs and other therapies (mostly lipid-lowering regimens). Yet worldwide, general practitioners continue to focus their attention on the management of a single risk factor, e.g. blood pressure, rather than on the global cardiovascular risk profile. Modern strategies of cardiovascular prevention should assess the global cardiovascular risk threshold to manage hypertensive patients at high risk, rather than to focus on the high level of a single risk factor, for achieving effective control of cardiovascular risk profile and reducing cardiovascular morbidity and mortality in the general population, as well as in the hypertensive population. In this regard, recent clinical studies have demonstrated that specific antihypertensive classes of drugs, such as those inhibiting the renin-angiotensin system and calcium antagonists, may confer clinical benefits across the spectrum of cardiovascular disease, from patients with conditions predisposing to cardiovascular events, such as left ventricular hypertrophy, microalbuminuria and diabetes mellitus, to patients with coronary artery disease or stroke, congestive heart failure and end-stage renal disease. Data from these studies suggest that the cardiovascular protection achieved by these drugs is, at least in part, independent from the blood pressure-lowering effect.