Are there benefits of antihypertensive therapy beyond blood pressure lowering?

Meta-analyses strongly suggest that the primary preventive benefit of antihypertensive therapy in uncomplicated individuals is the direct result of the lower blood pressure (BP) rather than the choice of agents. In contrast, when comorbidities are present, therapeutic benefit is governed primarily by the appropriateness of the drug class for the comorbidity profile. As progressively lower BP levels are studied, conflicting results and uncertainties continue to emerge. Given the geometric nature of the BP-risk relationship, it is to be expected that benefits will be less dramatic at lower levels of BP. Conflicting results may emerge from intrinsic problems with clinical trials, including uncertainties related to confounded composite end points, interactions of comorbidities, selection bias from the heterogeneous population with hypertension, interindividual response differences, BP variation and measurement artifacts, multiple mechanisms of antihypertensive drugs, and other deficiencies in study design. The mandate for BP reduction remains strong in virtually all clinical situations. Because of clinical heterogeneity, however, no single drug class is preferred in all circumstances.