When is one really hypertensive? From guidelines to everyday life, to each his own answer

Those with white hair will remember how a few decades ago there was a simple calculation to define the optimum maximum blood pressure. Just add your age to 100. Easy, intuitive, certainly easy to monitor. Then, progressively, it went down to first 160 systolic and 95 minimum. Then, in this progressive decline, we arrived at today's optimum levels, with the classic 120/80 (let's say, however, that up to 130 we are still in the range of normality, while above we already speak of pre-hypertension) millimetres of mercury optimum. All this, of course, has led to a progressive increase in the number of people with hypertension. If on the cardiovascular risk front there is evidence that lowering the optimal values has an impact on heart attack and stroke, as has also happened with LDL cholesterol, under the aspect of lifestyle and medication the approach has led to many more people taking therapies, with potential side effects lurking, in a logic that sees the cost-benefit profile of blood pressure lowering always clearly in favour of the latter in terms of population, but with obvious subjective variations that impact on the general well-being of the individual, especially in the presence of chronic poly-diseases that induce the need to take several treatments every day, with obvious effects on therapeutic adherence.

Bringing attention to the issue is research by experts from the University of Bologna that appeared in Medical Sciences. The authors point out how 'according to recent estimates, 1.4 billion adults between the ages of 30 and 79 are currently living with a diagnosis of hypertension, which is a major risk factor for several life-threatening cerebrovascular and cardiovascular diseases. And it is at this point that we need to reflect, moving from a discourse in terms of population to the subjectivity of the individual. Because, thanks to treatment, the cardiovascular risk is reduced, but attention must be paid to the acceptable values above which high blood pressure becomes a problem. In this sense, the race to the bottom dictated by the guidelines on the one hand has reduced the risk level of millions of people, but on the other hand has increased the number of patients eligible for drug therapy or more intensive treatment schemes. With increased costs but above all with many more people not reaching the desired target. "Moving the threshold values downwards does not only lead to a change in the status - from healthy to sick - of millions of people, but also means that many patients already on treatment can no longer reach the new, now lower, pressure targets, and therefore need higher doses of drugs," comments Lamberto Manzoli, professor at the Department of Medical and Surgical Sciences at the University of Bologna.

When it comes to cardiovascular prevention, people are presented with a patchwork of behaviours and goals that make it difficult to understand the weight of each individual risk factor. And one wonders how much of an impact it really has on the risk of heart attack and stroke (as well as kidney disease and others) to act so broadly on so many goals. "Five modifiable risk factors explain more or less half of the global burden of cardiovascular disease: they are hypertension, diabetes, smoking, hypercholesterolaemia and obesity," explains Francesco Prati, President of the Centro per la Lotta contro l'Infarto Fondazione Onlus and Director of the Cardiovascular Department of the Azienda Ospedaliera San Giovanni Addolorata in Rome. This means that half of all cardiovascular events would theoretically not exist if these factors were controlled'. This is according to the findings of the Global Cardiovascular Risk Consortium, which analysed over two million individuals from 133 international cohorts in primary prevention, estimating the impact of risk factors in terms of life expectancy and years free from cardiovascular disease, also considering what happens when the factors are eliminated between the ages of 55 and 60, i.e. at a stage of life when it is often considered 'too late'. The survey shows that not all risk factors have the same prognostic weight. "The absence of diabetes and smoking produces the greatest gain in years of life and in years free of cardiovascular disease: about 4-5 years without events and 5-6 years of additional survival," Prati reports. Systolic blood pressure below 130 millimetres of mercury, low non-HDL cholesterol and normal weight contribute smaller benefits, in the order of 1-3 years. However, hypertension emerges as the main determinant of cardiovascular-free years, while smoking remains the most powerful factor on overall mortality, because it affects the cardiovascular, respiratory and oncological systems simultaneously -'. Caution: According to the study, reducing hypertension, dyslipidaemia, diabetes and smoking between the ages of 55 and 60 produces measurable and clinically relevant benefits. The absence of hypertension in this age group guarantees the greatest gain in event-free years.

At the end of this reasoning, what should one do? Adding a piece to the mosaic of knowledge that leads one to think how important the 120 millimetre mercury threshold is for maximum has recently come a study that appeared in Annals of Internal Medicine and was carried out by researchers at Brigham and Women's Hospital in Boston. Basically, by examining a wealth of information from studies such as the Systolic Blood Pressure Intervention Trial (SPRINT) and the National Health and Nutrition Examination Survey (NHANES), the experts saw that aiming for a systolic blood pressure of less than 120 millimetres of mercury prevents more heart attacks, strokes and more than a target of 130 or even more than 140. All this, even taking into account the potential undesirable effects linked to the individual patient's treatment. But from the same academics comes another warning. Rather than striving for targets that are difficult to reach, it is better to leave the blood pressure a little higher, but still within normal values, especially in the case of the elderly. Final tip: follow the indications of the hypertension guidelines of the American Heart Association and the American College of Cardiology, published in Circulation, Hypertension, and the Journal of American College of Cardiology. What is important is to remember that hypertension can silently kill or otherwise change the trajectory of a person's health. And so it is necessary to play in advance. First of all by checking values regularly without burying one's head in the sand. And then by relying on the doctor, considering not only this danger index but the entire cardiovascular risk profile. This is how one arrives at a treatment aimed at the ideal target. Case by case. With a recall to optimal/normal values. We are in the normal pressure range with values below 120/80 millimetres of mercury. And according to US indications we are talking about high blood pressure with values between 120 and 129/80, stage 1 hypertension between 130 and 139 for the maximum or between 80 and 89 for the minimum. With higher values for systolic and diastolic we are already in the field of stage 2 hypertension.