Editorial Comment

Can the development of severe hypertension be predicted? Bernard Waeber and Franc¸ois Feihl

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t is a common knowledge that there is a direct relationship between the level of blood pressure (BP) and the risk for cardiovascular and renal morbidity. Also well established is the importance of detecting and treating hypertension as soon as possible, preferably before the onset of complications. Hence, the early identification of patients at risk of developing severe hypertension would be very useful, greatly helping the clinician to optimize their management and, potentially, to prevent the development of this condition. In their study, Westerdahl et al. [1] attempted to detect one or several factors associated with the development of severe hypertension over the following years in a general population. The implications for individuals presenting such risk factors could be substantial, as this same study demonstrates a negative impact of severe hypertension, once installed, on the subsequent development of diabetes and cardiovascular complications, as well as on mortality. The observations come from a Swedish populationbased cohort, in which 33 000 individuals were investigated on a first visit, 18 200 of whom were reexamined 20–25 years later [2–4]. To be noted in this study is the high initial acceptance rate and the availability of a national registry, which allowed a reliable follow-up of the enrolled individuals [5]. The design of this study presents with some limitations that one might regret. On the screening visit, individuals not taking antihypertensive medication on a regular basis were considered hypertensive if their BP exceeded 160/100 mmHg, a threshold above the standard currently used in most adults (140/90 mmHg). Another element reducing the practical interest of these observations is the exclusive reliance on office BP, with apparently no data obtained with ambulatory monitoring or self-measurement. These methodological limitations are likely to have greatly affected Journal of Hypertension 2014, 32:2353–2354 Division of Clinical Pathophysiology, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland Correspondence to Bernard Waeber, Professor, Centre Hospitalier Universitaire Vaudois, PPA MP14-02-224, CH-1011, Lausanne, Switzerland. Tel: +41 79 556 12 31; e-mail: [email protected] J Hypertens 32:2353–2354 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. DOI:10.1097/HJH.0000000000000386

Journal of Hypertension

the reported prevalence of hypertension on the first visit and the number of patients considered having severe hypertension on follow-up. Perhaps, if ambulatory BP data were available, we might also have learnt whether severe hypertension develops more frequently in some conditions, for example, in masked hypertension or in presence of a ‘nondipping’ BP profile during the night. At study inclusion, the individuals were placed on an individualized intervention program. Unfortunately, we do not know whether the level of adherence to this program had any impact on the ultimate outcome. The same is true regarding the type, dose, and number of antihypertensive agents used in the course of follow-up. It is possible that those patients whose BP was best controlled with medication were also the least likely to develop severe hypertension. What does this study tell us? First, that a family history of hypertension entails an increased risk of developing severe hypertension, thus underscoring for physicians the importance of careful history taking when meeting the patient for the first time. This finding is not entirely surprising, considering the known genetic component of hypertension. The respective influences of the maternal and paternal sides were assessed, and turned out to be different in men and women, but this finding is not very reliable because of the relatively small numbers of individuals involved. It is best to retain that, regardless of the parent’s sex, a family history of hypertension predisposes to severe hypertension. In addition, individuals prone to severe hypertension tend to have a profile compatible with a metabolic syndrome. In these patients, therefore, the cardiovascular risk is relatively high, and it is crucial that the physician should search for and correct each risk factor. Finally, severe hypertension is associated with significantly increased mortality, incidence of cardiovascular events, as well as new onset of diabetes and atrial fibrillation. This comparison was made with normotensive individuals matched for age and sex. Of additional interest would have been a comparison with lightly or moderately hypertensive patients. In the last decades, and especially in cardiovascular medicine, cohort studies have been an invaluable source of knowledge. In particular, so has been the Malmo¨ Preventive Project. Regarding hypertension, however, we must recognize that cohorts set up many years ago are bringing ever more limited information. This is because, in the www.jhypertension.com


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Waeber and Feihl

course of years, the definition of hypertension and the target BP for optimal management have changed, the spectrum of efficient and well tolerated antihypertensive drugs has widened, and the global management of cardiovascular risk factors has intensified. Today’s and yesterday’s hypertensive patients are increasingly different, hence the need for new cohorts, adapted to the present situation, notably with due consideration given to the genetic aspects of hypertension.

ACKNOWLEDGEMENTS Conflicts of interest There are no conflicts of interest.



REFERENCES 1. Westerdahl C, Zo¨ller B, Aslan E, Erdine S, Nilsson PM. Morbidity and mortality risk among patients with screening-detected severe hypertension in the Malmo¨ Preventive Project. J Hypertens 2014; 32:2378–2384. 2. Trell E. Community-based preventive medical department for individual risk factor assessment and intervention in an urban population. Prev Med 1983; 12:397–402. 3. Berglund G, Eriksson KF, Israelsson B, Kjellstrom T, Lindgarde F, Mattiasson I, et al. Cardiovascular risk groups and mortality in an urban Swedish male population: the Malmo Preventive Project. J Intern Med 1996; 239:489–497. 4. Berglund G, Nilsson P, Eriksson KF, Nilsson JA, Hedblad B, Kristenson H, et al. Long-term outcome of the Malmo preventive project: mortality and cardiovascular morbidity. J Intern Med 2000; 247:19–29. 5. Calltorp J, Adami HO, Astrom H, Fryklund L, Rossner S, Trolle Y, et al. Country profile: Sweden. Lancet 1996; 347:587–594.

Volume 32  Number 12  December 2014

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Can the development of severe hypertension be predicted?

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