There is a need for more aggressive implementation of combination strategies to control hypertensive risk.

Despite major efforts to improve detection, treatment and follow-up, inadequate management of risk patients remains one of the leading causes of excess cardiovascular morbidity and mortality worldwide (1). In order to come to grips with this situation, there is clearly an urgent need to improve identification, quantification and management of cardiovascular risk in the hypertensive population. Inadequate risk assessment leads to serious underestimation of the risk level in many patients and poor quantification of total cardiovascular risk will have serious consequences for the choice of appropriate treatment. Hypertension remains an area of medicine where major improvements can be made, since in spite of intense clinical and research, goal blood pressure levels are rarely achieved (2). The decision to initiate antihypertensive treatment is based on clinical, ambulatory or home assessment of systolic and diastolic blood pressure as well as additional risk factors in order to calculate the level of total cardiovascular risk. The evident goal is to achieve maximum reduction in the long-term total risk of cardiovascular morbidity and mortality at the expense of minimal adverse effects and costs. This requires a focused and optimized management of all the reversible risk factors identified, including smoking, dyslipidemia, abdominal obesity or diabetes, as well as appropriate management of associated clinical conditions. Recent randomized trials demonstrate that irrespective of what mode of blood pressure lowering, reduction of blood pressure to v140 and v90 mmHg, markedly and costeffectively reduces cardiovascular morbid and fatal events as compared to those remaining even moderately above these values (3). However, in spite of overwhelming evidence of the benefits of treatment, primary hypertension still remains underdiagnosed and under-treated, resulting in an excess of strokes and heart attacks that are potentially preventable (2). Several evidence-based guidelines offer guidance on appropriate blood pressure targets. Current evidence based on analyses of randomized trials, provide evidence that a value of at least v140/ 90 mmHg should be the blood pressure target in the whole hypertensive population. Still, however, the level to which blood pressure should be reduced to achieve maximum benefit remains to be settled. It is obvious that in diabetic patients as well as in patients at increased risk, the target systolic as well as diastolic blood pressures should be even lower, although this remains poorly implemented in the everyday clinical setting (4). Thus, it is increasingly evident, that reality does not match ambition, theory and guidelines (2). Despite widespread use of multidrug combination treatments, even in the setting of clinical outcome trials, the achieved average systolic blood pressure has remained above 140 mmHg (5), with control rates of most 60–70% of the recruited and treated patient population. More importantly, in diabetic patients on-treatment average values v130 mmHg are rarely obtained, resulting in blood pressure control being achieved in at most 30% of the patients. Clearly, reaching the recommended target blood pressures are difficult and should be the focus for increased efforts, both in terms of research and clinical management. In patients where initial blood pressures are high, the difficulties are even greater. Commonly, combination of two or more antihypertensive drugs has been the most widely used treatment strategy to obtain appropriate blood pressure lowering and to reach predetermined diastolic and systolic blood pressure goals. Notably, in the recent ASCOT trial on high-risk hypertensive patients, two or more antihypertensive drugs had to given to about 9/10 patients in order to reduce blood pressure v140/90 mmHg (6). Moreover, additional trial evidence show that, even for the same or even a greater use of combination treatment in diabetic patients, achieved systolic blood pressure generally remains higher than in non-diabetics (5). Therefore, in the future it is evident that physicians involved in the management of hypertensive patients have to recognize that combination treatments will have to be implemented earlier in the course of hypertension management. Combinations, based on a calcium antagonist and an ACE inhibitor, are clearly effective and well tolerated. Fixed-dose Blood Pressure. 2007; 16(Suppl 1): 4–5