What are the potential consequences of overtreating a patient with chronic severe hypertension (high blood pressure) for many years?

From the Guidelines

Overtreating a patient with chronic severe hypertension can lead to cerebral hypoperfusion, resulting in ischemic stroke, syncope, falls, or cognitive impairment, and therefore, blood pressure should be lowered gradually, aiming for a reduction of no more than 25% in the first 24 hours, then gradually working toward a goal of <140/90 mmHg over weeks to months, as recommended by the most recent guidelines 1. The potential consequences of overtreating a patient with chronic severe hypertension include:

• Cerebral hypoperfusion, which may result in ischemic stroke, syncope, falls, or cognitive impairment
• Acute kidney injury, especially in patients with underlying renal artery stenosis
• Orthostatic hypotension causing dizziness and falls These complications can be avoided by lowering blood pressure gradually, typically aiming for a reduction of no more than 25% in the first 24 hours, then gradually working toward a goal of <140/90 mmHg over weeks to months. Starting with low doses of medications like amlodipine 2.5mg daily or lisinopril 5mg daily and titrating slowly while monitoring for symptoms of hypoperfusion is recommended, as supported by recent studies 1. Regular follow-up with blood pressure checks and symptom assessment is essential to ensure safe and effective treatment. It is also important to consider the patient's individual risk factors and comorbidities when determining the optimal blood pressure target, as recommended by the ESC/ESH guidelines 1. The benefit/harm ratio for overtreatment of BP was shown in recent analyses demonstrating that only those with >18% 10-year CV risk derived more benefit than harm from aggressive BP-lowering treatment 1. Therefore, a more evidence-based approach would be to set the lower BP target for treatment at >15% 10-year CV risk, as suggested by recent studies 1.

From the FDA Drug Label

Lowering blood pressure lowers the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit

The potential consequences of overtreating a patient with chronic severe hypertension are not directly addressed in the provided drug label. Key points to consider in managing hypertension include:

• Lowering blood pressure to reduce cardiovascular risk
• Individualized treatment goals based on patient-specific factors
• Potential benefits of aggressive treatment in high-risk patients However, the label does not provide information on the consequences of overtreating hypertension 2.

From the Research

Potential Consequences of Overtreating Chronic Severe Hypertension

• Overtreating patients with chronic severe hypertension may lead to increased risk of adverse events, such as orthostatic hypotension, orthostatic dizziness, weakness, and serum creatinine elevation 3
• Lowering blood pressure too much, below 120/70 mmHg, may actually be harmful and increase cardiovascular mortality and events 3
• Studies have shown that targeting blood pressure below 130/80 mmHg may not provide additional benefits in reducing mortality and morbidity, and may even increase the risk of adverse events 4, 5
• The "lower the better" approach to blood pressure treatment has been challenged, and the optimal blood pressure target in people with hypertension and established cardiovascular disease remains unknown 4, 5
• Some studies suggest that the benefits of lower blood pressure targets do not outweigh the harms, and that the standard blood pressure target of less than 140/90 mmHg may be sufficient for most patients 4, 5
• However, other studies suggest that intensive blood pressure lowering may be beneficial in reducing cardiovascular outcomes, particularly in younger patients with a lower burden of comorbidities 6
• The relationship between diastolic pressure and coronary events is complex, and the existence of a J-curve, where further reduction of diastolic pressure below a certain point increases cardiovascular mortality and myocardial infarctions, is still a topic of debate 7

Considerations for Treatment Targets

• The American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guideline and the European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guideline recommend targeting blood pressure below 130/80 mmHg in most hypertensive subjects 3
• However, these guidelines also emphasize the importance of individualizing treatment targets based on patient characteristics, such as age, comorbidities, and cardiovascular risk 3
• The choice of treatment target should be based on a careful consideration of the potential benefits and harms of different blood pressure targets, as well as the individual patient's preferences and values 4, 5