Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension

By: Peter M Rothwell

Abstract: Although hypertension is the most prevalent treatable vascular risk factor, how it causes end-organ damage and vascular events are poorly understood. Yet, a widespread belief exists that underlying usual blood pressure can alone account for all blood-pressure-related risk of vascular events and for the benefits of antihypertensive drugs, and this notion has come to underpin all major clinical guidelines on diagnosis and treatment of hypertension. Other potentially informative measures, such as variability in clinic blood pressure or maximum blood pressure reached, have been neglected, and the effects of antihypertensive drugs on such measures are largely unknown. Clinical guidelines recommend that episodic hypertension is not treated, and the potential risks of residual variability in blood pressure in treated hypertensive patients have been ignored. This Review discusses the shortcomings of the usual blood-pressure hypothesis provides background to accompanying reports on the importance of blood-pressure variability in prediction of risk of vascular events and in accounting for benefits of antihypertensive drugs and draws attention to clinical implications and directions for future research.

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The Lancet | Vol 375 | March 13, 2010