How early should blood pressure control be achieved for optimal cardiovascular outcomes?

As a consequence of the aging population and the increasing prevalence rates for conditions such as type 2 diabetes and chronic kidney disease (CKD), management of hypertension will be focusing more and more on the high-risk patient. Clinical practice guidelines for managing hypertension in the United States recommend a target blood pressure (BP) <130/80 mm Hg in patients with diabetes or CKD, notably lower than the 140/90-mm Hg threshold for the general hypertensive population. However, the optimal timeframe from initiation of antihypertensive therapy to attaining these levels of BP control and influencing cardiovascular outcomes is not as well defined. Overall, a series of landmark BP intervention trials in patients with hypertension and additional cardiovascular risk factors collectively support that achieving prompt BP control, ideally within 1-3 months, translates into improved cardiovascular outcomes. Although the consistency of the findings is encouraging, the strength of this conclusion is limited by the available data, which were derived from studies not designed to determine the definition or benefits of early BP reduction. In several of these studies, using a treatment approach with initial monotherapy or combination therapy has clearly demonstrated pronounced BP lowering and high BP control rates within an intensive timeframe of 3-6 months of therapy. Although these studies were not conducted exclusively in high-risk patients, subgroup analyses have demonstrated that the observed outcomes in the overall study populations apply to the diabetic and CKD subsets.