New York, NY - With an estimated 1.5 billion people expected to be hypertensive by 2025, an argument making the case that hypertension is "uncontrolled and conquering the world" is not hyperbole. This staggering number, as well as the fact that the risk of becoming hypertensive is greater than 90% for individuals in developed countries, highlights the growing problem of uncontrolled hypertension, both in developed as well as undeveloped countries, according to an editorial appearing in the August 18, 2007 issue of the Lancet [1].

"Many people still believe that hypertension is a disease that can be cured, and stop or reduce medication when blood-pressure levels fall," the Lancet editorialists write. "Physicians need to convey the message that hypertension is the first and easily measurable irreversible sign that many organs in the body are under attack. Perhaps this message will also make people think more carefully about the consequences of an unhealthy lifestyle and help to give preventive measures a real chance of success."

Hypertension, according to the Lancet, remains a problematic disorder, despite functioning healthcare systems, a large number of available effective treatments, and overwhelming evidence in various patient populations. Screening for hypertension, they point out, is not done systematically, and diagnosis is often made at a late stage when target-organ damage has already started. In addition, the optimum time to start treatment remains "under discussion."

In addition to the editorial, Drs Franz Messerli (St Luke's-Roosevelt Hospital, New York), Bryan Williams (University of Leicester School of Medicine, UK), and Eberhard Ritz (University of Heidelberg, Germany) wrote an accompanying seminar discussing essential hypertension, its treatments, associated comorbidities, and lessons learned from various clinical trials [2].

As noted in the editorial and seminar, treatment guidelines still use the threshold model for recommendations, where hypertension is diagnosed when systolic blood pressure is >139 mm Hg or diastolic blood pressure is >89 mm Hg. "The issue of prehypertension has stirred tempers to an extent that seems more suitable to medieval theologians than modern scientists," write Messerli, Williams, and Ritz. "Epidemiological evidence suggests a continuous relation between risk of cardiovascular disease and usual blood-pressure values of at least 115/75 mm Hg."

In the Framingham cohort, the authors note, there is a stepwise increase in cardiovascular events in individuals with high baseline blood pressure within the normotensive range. In people without hypertension, those with blood-pressure levels <140/90 mm Hg, blood-pressure levels parallel cardiovascular disease risk in the same way as hypertension, they point out.

Both the editorial and seminar authors point out that compliance remains one of the biggest barriers to treating hypertension, despite very effective and cost-effective treatments. Even a Rhodes scholar, such as former President Bill Clinton, was under the false impression that medication can be stopped once blood pressure is lowered. While lifestyle interventions—low-salt diet, weight loss, exercise, and alcohol restriction—remain the preferred means of lowering blood-pressure levels, adherence to these changes is "notoriously poor," and antihypertensive medications might need to be considered in even some normotensive individuals, argue Messerli, Williams, and Ritz.

The authors note that patients respond differently to the drug classes and that the most "important question to ask when selecting initial drug treatment is which class of drug will deliver the most effective blood-pressure lowering." For patients with blood pressure 20 mm Hg or more above goal, the guidelines recommend two-drug combinations, as monotherapy is likely to be insufficient. High-risk hypertensive patients not only should receive combination therapy for optimum blood-pressure control but also should receive a statin and low-dose aspirin, add Messerli and colleagues.