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Menopause Live - IMS Updates
InFocus

Date of release: 09 November, 2009

Hypertension treatment 2009 – a new model?


As much as it sounds unbelievable, it seems that pharmacological treatment of ‘mild’ hypertension in patients with low or moderate cardiovascular risk may not influence cardiovascular morbidity or mortality. A 2009 Cochrane review of the literature on treatment-of-hypertension targets [1] pointed out that no trials comparing different systolic blood pressure targets were found, and only seven trials (22,089 subjects) comparing different diastolic blood pressure targets were identified. Analysis of the data concluded that an attempt to achieve lower blood pressure targets instead of standard targets (< 140/90 mmHg) did not change the outcomes. In fact, this strategy did not prolong survival or reduce the risk for stroke, heart attack, heart failure or kidney failure. The authors pointed out that the net health effect of lower targets could not be fully assessed due to lack of information regarding all total serious adverse events and withdrawals due to adverse effects.


In the October edition of the Journal of Hypertension, the European Society of Hypertension has published a very long and detailed document [2] updating a previous statement issued in 2007. The relevant recommendations for non-elderly patients with grade 1 hypertension (blood pressure < 159/99 mmHg) who are at low or moderate cardiovascular risk are as follows. Non-pharmacological measures, such as lifestyle modifications should be initiated first and, only if unsuccessful, treatment with medications may be considered. However, once again this document stresses the fact that the evidence in favor of drug therapy in this clinical set-up is scanty. Also, it is stated that a too-drastic lowering of blood pressure (< 120/70 mmHg) may carry a risk (the J-curve phenomenon). As for the medications themselves, all groups are suitable, including beta-blockers, which were previously removed from the list.

Comment

One of the foci of interest for the educational activities of the International Menopause Society in recent years has been the issue of prevention of cardiovascular disease in women. The IMS collaborated with the European Society of Hypertension and the European Society of Cardiology and, as a result of this joint project, a booklet entitled Assessment and management of cardiovascular risks in women was produced and distributed around the world. The booklet is also available on the IMS website, www.imsociety.org. 
I think that we should pay attention to the cautious phrasing in the new statement: . . . ‘it appears reasonable to recommend that, in Grade 1 hypertensives at low and moderate risk, drug therapy should be started after a suitable period with lifestyle changes’. This vague advice perhaps indicates that, in people with low and moderate cardiovascular risk, one should not prescribe medications as a routine. The rules in regard to statin therapy for primary cardioprevention in women have been heavily debated recently, since there is insufficient evidence to suggest its use in women with low to moderate cardiovascular risk [3]. According to new recommendations, aspirin – a very popular drug that reduces the risk for coronary events and strokes – should not be used for primary prevention in women unless they are older than 70 years or have a five-fold increased risk for cardiovascular events [4]. Thus it seems that in 2009 the benefit–risk balance for pharmacological interventions in the case of low-to-moderate cardiovascular risk dictates a more conservative approach. This puts education for lifestyle modifications (eat healthy, be physically active, no smoking) in the forefront of any strategy aimed at primary prevention of cardiovascular disease.

Comentario

Amos Pines
Department of Medicine T, Ichilov Hospital, Tel-Aviv, Israel

    References

  1. Arquedas JA, Perez MI, Wright JM. Treatment blood pressure targets for hypertension. Cochrane Database Syst Rev 2009 Jul 8;(3):CD004349.
    http://www.ncbi.nlm.nih.gov/pubmed/19588353

  2. Mancia G, Laurent S, Agabiti-Rosei E, et al. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypert 2009. Epub ahead of print, Oct 15
    http://www.ncbi.nlm.nih.gov/pubmed/19838131

  3. Walsh JM, Pignone M. Drug treatment of hyperlipidemia in women. JAMA 2004;291:2243-52.
    http://www.ncbi.nlm.nih.gov/pubmed/15138247

  4. Algra A, Greving JP. Aspirin in primary prevention: sex and baseline risk matter. Lancet 2009;373:1821-2.
    http://www.ncbi.nlm.nih.gov/pubmed/19482200