These recommendations are presented in abbreviated form. Readers should refer to the text of the complete guideline document1 for a detailed discussion of each of the following topics.
Systolic, diastolic and pulse pressures as predictors
Historically more emphasis has been placed on diastolic than systolic blood pressure as a predictor of cerebrovascular and coronary heart disease. This was reflected in the design of the major randomized controlled trials of hypertension management which, almost universally, used diastolic blood pressure thresholds as inclusion criteria until the 1990s. Subjects with isolated systolic hypertension were excluded by definition from such trials. Nevertheless, large compilations of observational data before and since the 1990s confirm that both systolic and diastolic blood pressures show a continuous graded independent relationship with risk of stroke and coronary events.
In the European context, the relationship between systolic blood pressure and relative risk of stroke is steeper than that for coronary events, which reflects the closer aetiological relationship with stroke. However, the attributable risk – that is excess deaths due to raised blood pressure – is greater for coronary events than for stroke, reflecting the higher incidence of heart
disease in most of Europe. This notwithstanding, the relative incidence of stroke is increasing in our ageing population, as shown in recent randomized controlled trials.
The apparently simple direct relationship between increasing systolic and diastolic blood pressures and cardiovascular risk is confounded by the fact that systolic blood pressure rises throughout the adult age range in European (as well as in many non-European) populations, whereas diastolic blood pressure peaks at about age 60 years in men and 70 years in women, and falls gradually thereafter. These phenomena represent the results of some of the pathological processes that underlie ‘hypertension’ and cardiovascular diseases.
| Blood pressure (mmHg) |
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| Other risk factors and disease history | Normal: SBP 120–129 or DBP 80–84 |
High normal: SBP 130–139 or DBP 85–89 |
Grade 1: SBP 140–159 or DBP 90–99 |
Grade 2: SBP 160–179 or DBP 100–109 |
Grade 3: SBP > 180 or DBP > 110 |
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| No other risk factors | Average risk | Average risk | Low added risk | Moderate added risk | High added risk |
| 1-2 risk factors | Low added risk | Low added risk | Moderate added risk | Moderate added risk | Very high added risk |
| 3 or more risk factors or TOD or diabetes | Moderate added risk | High added risk | High added risk | High added risk | Very high added risk |
| ACC | High added risk | Very high added risk | Very high added risk | Very high added risk | Very high added risk |
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| ACC, associated clinical conditions; TOD, target organ damage; SBP, systolic blood pressure; DBP, diastolic blood pressure. | |||||
References:
1. 2003 European Society of Hypertension–European Society of Cardiology guidelines for the management of arterial hypertension. Journal of Hypertension 2003, 21:1011–1053. Available at http://www.eshonline.org/.