Office Blood Pressure and Cardiovascular Disease: Pathophysiologic Implications for Diagnosis and Treatment

Ease of the indirect measurement of office blood pressure  (BP) and the robust database demonstrating a linear and direct relationship between office BP and future cardiovascular morbid events (MEs)1 has led to the widely held view that an elevated BP defines a disease, hypertension.2 The similarly robust data demonstrating that drugs that reduce an elevated BP reduce the risk for ME3 has fueled the guidelines that recommend treatment to lower BP in this disease.4,5 Indeed, the data on office BP reduction as a therapeutic target has led the Food and Drug Administration to violate their traditional demand that approved therapy make people feel better or live longer and to instead accept BP lowering alone as an adequate measure of effectiveness. The goal of this review is to critically examine the rationale for using office BP as the primary guide to the diagnosis and treatment of hypertensive cardiovascular disease. Since the diagnostic value of office BP and therapeutic efficacy of its reduction has been established, the issues that have in recent years consumed the attention of clinical trialists and guideline developers have related to the threshold of BP that requires treatment, the method for assessing the BP, the appropriate target for therapy, and whether certain therapeutic agents are preferable to others in achieving the goal of risk reduction via BP lowering. Numeric criteria for the diagnosis of hypertension have undergone scrutiny because of the recognition that rigid thresholds for diagnosis and treatment may exclude some individuals in need of assessment or treatment.6 Two recent events have generated considerable controversy: (1) a recommendation that systolic BP <150 mm Hg need not be treated in individuals over age 60 years,5 and (2) a study demonstrating that therapy targeting a BP of <120 mm Hg is superior in …