Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document.

Many important decisions on hypertension management must currently be taken without the support of evidence from large randomized controlled trials. The following issues appear in urgent need to be approached by simply designed trials. (1) Should antihypertensive drugs be prescribed to all patients with grade 1 hypertension, even when total cardiovascular risk is relatively low or moderate? Because of the very low rate of cardiovascular events expected in these patients, a placebo-controlled trial using intermediate endpoints such as signs of organ damage of recognized prognostic importance would be feasible, ethical, and clinically relevant. (2) Should antihypertensive drugs be prescribed to the elderly with grade 1 hypertension, and should antihypertensive treatment achieve a goal of below 140/90mmHg also in the elderly? These trials could make use of hard cardiovascular outcomes and could be placebo-controlled. (3) Should antihypertensive drug treatment be started in diabetic patients or in patients with previous cerebrovascular or cardiovascular disease when BP is still in the high normal level, and should BP goal be below 130/ 80mmHg in these patients? These issues can be approached by placebo-controlled trials because no trial evidence is still available on the benefit of lowering high normal BP or of achieving BP goals below 130/ 80mmHg. (4) What are the lowest safe BP values to achieve by treatment in different clinical conditions? This issue should be approached by trials comparing more or less intense BP-lowering treatment strategies in patients with different cardiovascular risk levels. (5) Are lifestyle measures known to reduce BP also capable of reducing morbidity and mortality in hypertension? A controlled randomized trial using intermediate endpoints (organ damage) would be feasible and desirable in patients with high normal BP or grade 1 hypertension.