Clinical question	Bottom-line answer
1. Blood pressure target	Lower target had a mixture of benefits and harms in high-risk patients.
Is there a net benefit to a systolic blood pressure target of 120 mm Hg compared with 140 mm Hg in patients without diabetes mellitus who are at high risk of CV disease?⁹	In this group of older patients (mean age = 68 years) who do not have diabetes but are at high risk of CV disease, a more aggressive systolic blood pressure target of 120 mm Hg instead of 140 mm Hg led to benefits (lower all-cause mortality, lower CV mortality, less heart failure), but also some harms (more serious episodes of hypotension, electrolyte abnormality, syncope, and acute kidney injury). Patients in the intensive therapy group took an average of one additional drug to achieve this target. The decision to pursue this more aggressive target should be guided by how well the patient fits the profile of patients in this study (i.e., no diabetes, older than 50 years, high risk of CV disease) and how well the additional therapy is tolerated.
2. Blood pressure target	Use a target of 140 mm Hg systolic in intermediate-risk patients.
In patients with an intermediate risk of CV disease, does blood pressure lowering (regardless of initial blood pressure) improve clinical outcomes?¹⁰	This large randomized trial provides important guidance for primary care physicians and their patients. For patients at intermediate risk of CV disease who have a systolic blood pressure lower than 143 mm Hg, there is no benefit to prescribing candesartan/hydrochlorothiazide (Atacand HCT). For those with elevated blood pressure, there is a small benefit in terms of the composite outcome (number needed to treat = 59 over 5.6 years to prevent one CV death, nonfatal myocardial infarction, or nonfatal stroke) but no mortality benefit. The recent SPRINT (Systolic Blood Pressure Intervention Trial) trial found a benefit but in a much higher-risk group. This study supports current recommendations for limiting use of antihypertensives in low-risk and intermediate-risk patients to those with a systolic blood pressure higher than 140 mm Hg.
3. Intensive lowering of blood pressure	Intensive lowering had no meaningful effect on myocardial infarction, heart failure, or mortality.
Does intensive lowering of blood pressure improve the lives of patients with hypertension?¹¹	This meta-analysis of 19 trials with nearly 45,000 patients found that those who are treated more intensively are slightly less likely to have major CV events, stroke, or progression of albuminuria or retinopathy than those treated less intensively, but intensive lowering had no meaningful effect on myocardial infarction, heart failure, or mortality.
4. Effect of statins	Statins reduce risk of CV events by 25% regardless of baseline risk.
In persons at intermediate risk of a CV event, does medication to reduce blood pressure and cholesterol reduce the likelihood of CV events?¹²	This large randomized trial compared candesartan/hydrochlorothiazide with each drug alone and with placebo in more than 12,000 patients. The results confirm that treating elevated blood pressure reduces the likelihood of CV events and that statins provide a consistent relative reduction in risk of about 25%, regardless of the baseline risk. However, the effects were not synergistic.
5. Refractory hypertension	Spironolactone is an effective add-on medication for patients with hypertension not well controlled with three medications.
In patients with resistant hypertension (poor control despite the maximum dosages of three drugs), what is the most effective add-on medication?¹³	In 335 patients already receiving maximal dosages of three drugs, spironolactone, 25 mg once daily, was more effective than doxazosin (Cardura; 4 mg) or bisoprolol (Zebeta; 5 mg) at lowering blood pressure (4 to 5 mm Hg greater reduction). Whether this will result in better long-term control or decrease the rate of clinically important outcomes such as stroke, congestive heart failure, or kidney failure is unknown.
6. Hypertensive urgency	Rapid treatment is unnecessary for most patients.
How urgently should we aim to control hypertensive urgency, defined as systolic blood pressure above 180 mm Hg or diastolic blood pressure above 110 mm Hg?¹⁴	It seems that rapid treatment of patients with hypertensive urgency is both unsuccessful and unnecessary. In this study of almost 60,000 patients, 80% did not have controlled blood pressure (less than 140/less than 90 mm Hg) after one month of treatment, including patients who were hospitalized. On the other hand, the risk of a major CV event was also low: one in 1,000 over the next seven days.