Intended for healthcare professionals

Rapid response to:

Clinical Review State of the Art Review

Management of mild hypertension in adults

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5719 (Published 21 November 2016) Cite this as: BMJ 2016;355:i5719

Rapid Response:

Re: Management of mild hypertension in adults

We thank Drs. Hart and Barraclough for their thoughtful comments. We agree that our article reviews available literature for treating mild hypertension, which is limited and suboptimal. As discussed in the article, the benefits of blood pressure reduction in people with mild hypertension, especially those with low cardiovascular risk are not clear. Absolute risk reductions are indeed important to take into account when considering BP-lowering treatment. As the article points out, we suggest that absolute cardiovascular risk be assessed when considering the management of patients with mild hypertension (which is indeed a new paradigm that models modern approaches to lipid-lowering treatment and aspirin use for primary prevention). The relative risk reductions can then be used to estimate the absolute risk reductions. For patients with low CVD risk, the absolute risk reductions from treating mild hypertension will be small. On the other hand, for patients with high CVD risk, the absolute risk reductions will be of greater magnitude. These estimates can be used in shared-decision making discussions (weighing potential harms and potential benefits) with patients who have mild hypertension.

Our article compares and contrasts the two available meta-analyses. Of note, the 2015 analyses evaluated a larger sample size of subjects and included studies assessing more optimal pharmacotherapy. We did, in fact, mention in both table and text that most of the patients included in this analysis had diabetes. As we noted, the SPRINT trial was included to offer insight into blood pressure treatment goals despite not being a trial treating mild hypertension. In conclusion, given the low quality of evidence for treatment of mild hypertension, it is necessary to consider the cost of treatment, the pill burden, and the potential benefit and side effects when making a shared decision with patients.

Competing interests: No competing interests

02 January 2017
Anthony J. Viera
Professor
Emily Hawes
Chapel Hill, NC