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High normal blood pressure: to treat or not to treat?

Journal of Human Hypertension volume 29, pages 7–8 (2015)Cite this article

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High blood pressure (BP) remains the most common, readily identifiable and reversible risk factor for cardiovascular disease, stroke and death. Considering the enormous costs involved, it remains imperative to identify and implement effective approaches to achieve optimal control of this condition. However, any BP level used to define normal or high BP is arbitrary indeed. The view that BP is a continuous variable with no specific separation between normal and abnormal values was not always accepted, until a long and famous debate between Sir George Pickering and Lord Robert Platt in 1950s.1 The general consensus was that Pickering won and the unimodal rather than bimodal distribution holds sway. In clinical practice, however, cut-off BP values are universally accepted to simplify management even though epidemiologic data shows continuous, graded and etiologically significant positive relationship with cardiovascular outcome, even with BP values as low as 115/75 mm Hg.2 Thus, this artificial dichotomy between hypertension and normotension could prove detrimental and cause delay in medical treatment, irreversibly compromising vascular health by BP values considered to be normal.

The recent 2013 European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines for hypertension have proposed seven categories of BP levels.3 High normal BP (defined as systolic BP of 130–139 mm Hg and/or diastolic BP 85–89 mm Hg) has been shown to be associated not only with increased risk of developing hypertension4, 5 but also with risk of cardiovascular disease6 including atrial fibrillation.7 Prospective data from the Women’s Health Study8 also suggest that BP in the high normal range confers substantially higher risk of major cardiovascular events and incident hypertension than normal BP. In this issue of the JHH, Ueda et al. present interesting and methodological data from a prospective cohort elucidating the possible relation between high normal BP and evidence of organ damage represented by new-onset left ventricular hypertrophy (LVH) on electrocardiography (ECG). The authors, having examined >4000 subjects 3 years apart, conclude that high normal BP was related to new-onset LVH, a >2-fold higher risk compared with optimal BP, a finding that remained independent in multivariate analyses. This is thought provoking and at the same time complementing the results from previous studies that high normal BP is not entirely benign. The results as well suggest that the occurrence of target organ damage (LVH) with BP currently considered to be below the threshold for treatment could represent an early marker of future cardiovascular risk, and identifying these patients could help direct preventive strategies.

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Authors and Affiliations

  1. Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK

    A Ahmed & R Senior

  2. Department of Cardiology and Echocardiography Laboratory, Royal Brompton Hospital, Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, UK

    R Senior

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Correspondence to R Senior.

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Ahmed, A., Senior, R. High normal blood pressure: to treat or not to treat?. J Hum Hypertens 29, 7–8 (2015). https://doi.org/10.1038/jhh.2014.24

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