Prehypertension: the rationale for early drug therapy.

Blood pressure within prehypertensive levels confers higher cardiovascular risk by two means. At first, these levels are associated with higher risk for cardiovascular events, starting at BP values as low as 115/75 mmHg, and doubling at each 20 mmHg for systolic or 10 mmHg for diastolic BP. Prehypertension is also an intermediate stage for full hypertension, which develops in an annual rate of 7 out 100 individuals with 40-50 years of age. The precocious drug intervention in patients with prehypertension is therefore appealing. In individuals with previous cardiovascular disease or diabetes the use of BP-lowering agents is compulsory, since the 18-42% reduction of major cardiovascular events demonstrated in randomized clinical trials translates in palpable clinical benefit. In the absence of higher baseline risk, the absolute benefit of treatment is presumably small and was not demonstrated to date. These individuals could be candidate to treatment with the aim to prevent the development of full hypertension. The long-lasting effectiveness of non-drug therapies is low outside the controlled conditions of randomized clinical trials, and there are evidences that the use of BP-lowering drugs reduces the incidence of hypertension in individuals with prehypertension by more than 60%. Clinical trials testing the efficacy and safety of BP agents to prevent hypertension in a population-based perspective are required. In the meantime, it is worthy to present the option to start low doses of BP agents for individuals with prehypertension without co-morbidities who do not respond to the prescription of lifestyle modification.