From guidelines to current practices: Suboptimal hypertension management in France.

In France, the prevalence of hypertension is higher than 30%. Although treatment guidelines have been well established over the last twenty years, the national blood pressure control rate is below the average of high-income countries. This observational study aimed to describe the antihypertensive prescription behaviours of primary care physicians (PCPs) in France and to assess their compliance with current French guidelines, focusing on three specific prescription issues and their potential repercussions on blood pressure control: treatment initiation, treatment renewal or change and type of triple therapy. Prescription data were retrieved using the IQVIA longitudinal patient database (LPD), which delivers real-world data insights from French primary care electronic medical records (EMR). The average number of prescribed therapeutic agents was 1.9 per patient, with 39.3% monotherapy prescriptions. Treatment initiation represented 7.2% of all antihypertensive prescriptions. At treatment initiation, 22.5% of patients were prescribed dual therapy. The proportion of treatment renewal in the same therapeutic class was 74.3% while the proportion of treatment change was 18.5%. Of these, only 6.3% of patients received an additional therapy. Lastly, 35.7% of triple therapies were consistent with the recommended combinations. In conclusion, this study provides evidence of therapeutic gaps in hypertension management in France. The low blood control rate may be attributed to PCPs' therapeutic inertia and lack of knowledge of treatment guidelines. All stakeholders should commit to rapid corrective action in order to provide patients with the best care.

[A muscular calcium pyrophosphate deposition pseudo-abscess: An atypical localization of chondrocalcinosis]. / Pseudo-abcès musculaire d'origine microcristalline : une localisation exceptionnelle de chondrocalcinose.

INTRODUCTION: Chondrocalcinosis results from calcium pyrophosphate crystals deposition in the joints. We report an exceptional case of aseptic psoas abscess with a deposition of calcium pyrophosphate crystals. CASE REPORT: A 92-year-old man presented to our department for an acute onset of inflammatory pain in the left hip. Computed tomography detected a coxofemoral arthritis and multiple intramuscular collections located in the iliopsoas muscle and the gluteus minimus. A sample of the fluid was obtained with a guided aspiration, and its analysis revealed an inflammatory liquid with no bacteria but numerous calcium pyrophosphate crystals. The final diagnosis was thus a muscular calcium pyrophosphate deposition pseudo-abscess, associated with a hip arthritis. CONCLUSION: Hip chondrocalcinosis is unusual, and the association with intramuscular deposition of calcium pyrophosphate crystals seems extremely rare as we found only four other published cases. A microcrystalline arthritis could have spread from the coxofemoral joint through the iliopsoas bursa and into the muscle. However, the imaging aspect with an abscess and a predominant muscular injury might suggest a mechanism of crystal formation originating directly within the muscle. The outcome was always favourable even if some patients required surgery.

[Vitamine K antagonists overdose: Physician adherence to the French guidelines]. / Surdosages en antivitamines K : audit de la prise en charge hospitalière.

INTRODUCTION: Vitamin K antagonists (VKA) are drugs with a major risk of side effect. Guidelines have been published in 2008 by the Haute Autorité de santé (HAS) concerning the management of an excessively elevated INR ratio. Our research aimed to assess physicians' adherence to those guidelines. METHODS: We realized a retrospective, multicentric study. One hundred and ten cases of excessively elevated INR ratio were identified and analyzed. RESULTS: Overall physicians adherence was 58%. However, patients with the most elevated INR, i.e., INR>6, were treated according to guidelines in only 33% of the cases. The use of vitamin K was the major source of mistakes. The rate of mortality was 20%. CONCLUSION: Adherence to HAS guidelines seems finally limited. It is necessary to put in place procedures to secure the behavior of physicians.

[Usefulness of different techniques of blood pressure measurements in 2016]. / Place des différentes techniques de mesure de la pression artérielle en 2016.

The management of hypertensive patients is greatly influenced by blood pressure levels and accurate measurement of blood pressure is crucial in this context. Mercury sphygmomanometer has been progressively replaced by more precise oscillometric devices that can be widely used in the clinic and ambulatory setting. The purpose of this review was to detail the different methods for evaluating blood pressure, and to refine their indications and clinical benefit. Office blood pressure measurement has a great variability and should follow a strict protocol to give consistent results. National and international guidelines focus on blood pressure measurement in the ambulatory setting. When used by trained patients, home blood pressure monitoring is reproducible and can provide substantial prognostic information, even if ambulatory blood pressure monitoring remains the gold standard. The role of central blood pressure and pulse wave velocity monitoring in the therapeutic strategy of hypertension needs further assessment.

[Determinants of controlled hypertension in patients treated with antihypertensive drugs in France: The French League Against Hypertension Survey (FLAHS 2015)]. / Déterminants de l'hypertension artérielle contrôlée chez les sujets traités par antihypertenseurs en France : enquête FLAHS 2015.

OBJECTIVE: The FLASH 2015 survey sought the determinants of hypertension control in subjects treated with antihypertensive drugs in France. METHOD: Sending self-administered questionnaire by mail to a representative sample of the population living in metropolitan France (MetaScope basis, TNS Sofres, France). Patients who declare taking antihypertensive drugs are considered treated hypertensives. A home blood pressure monitoring during 3 days was asked in subjects owing a blood pressure monitor and the average of 18 measurements was calculated. RESULTS: A total of 6379 subjects aged 55 and older were included with 2814 (44.1%) treated with antihypertensive drugs. Home blood pressure was obtained from 1455 subjects including 882 (60.6%) treated. SBP/DBP are 129.3±13.5/75.5±9.0mmHg and are higher in treated subjects in each age category. BP<135/85 was observed in 55.4% and BP<140/90 in 71.7%. Determinants of BP control (<135/85) are the number of measurement for averaging (18 measures over 3 days vs 3 measurements on a morning; 55.4%/44.3%), age (55-64 years vs 80 years old; 57.6%/49.1%), gender (women vs men; 60.3%/50.1%), BMI (<25 vs >30; 63.1%/46.1%). In the 80 and older, a SBP<145 was observed in 74.7% of subjects. The control was 61% when considering an SBP/DBP<135/85 in 55-79 years and SBP<145 among 80 and older. CONCLUSION: The control of hypertension evaluated by home blood pressure on a representative population living in metropolitan France is estimated at between 44.3% and 74.7% and several determinants influence the control of blood pressure like age, gender and BMI.

[Hypertension in the elderly in France: Characteristics of treatments and frequency of cognitive complaint according to the 2014 French League against Hypertension Survey]. / Hypertension artérielle du sujet âgé en France : caractéristiques du traitement et fréquence de la plainte cognitive selon l'enquête FLAHS 2014.

OBJECTIVE: Describe hypertensive patients treated in 2014 in France by age and estimate the degree of cognitive complaint among subjects aged 55 and over. METHOD: French League against Hypertension Survey (FLAHS) was conducted by mail in a representative sample of subjects aged 35 and over living in metropolitan France. Antihypertensive treatment data were obtained by self-administered questionnaire. Among the owners of a self-measurement device, blood pressure was considered to be controlled if the average of three measurements in the morning was below 135/85 mmHg. Cognitive complaint was detected by the cognitive complaint questionnaire (QPC) and analyzed by age and medical history of each subject. RESULTS: In 2014, 30% of the population aged 35 and over (11.6 million) was treated with antihypertensive drugs. The number of treated hypertensive was: 3.45 million in the 75 and older, 2.96 million in 65-74 years, 3.24 million in 55-64 years, 1.58 million in the 45-54 years and 0.441 million in 35-44. The mono/bi/tri/quad-therapy is used in 46%/35%/14%/5% of patients. This distribution varies with age with monotherapy used in 63% of subjects under 55 years but in 40% of subjects 75 years and over. A positive QPC was noted in 11% of 55-64 years, in 21% of 75 years and older (P<0.001), in 20% of uncontrolled hypertensive patients, and in 34% of subjects with a personal history of stroke. CONCLUSION: In France, hypertension is a disease that affects mainly the elderly. The modalities of treatment are different depending on age. Cognitive complaints are more common in uncontrolled hypertensive patients and in patients with a history of stroke.

[Proper use of apixaban: an outline for clinical practice]. / Bon usage d'apixaban: que retenir pour la pratique.

Apixaban is a direct inhibitor of coagulation factor Xa. Superior efficacy over aspirin and antivitamin K has been shown in the prevention of stroke and systemic embolism during non-valvular atrial fibrillation with a more favorable safety profile, even though the risk of hemorrhage cannot be ignored, considering its mechanism of action. The recommended dose is 5mg twice daily which can be reduced to 2.5mg depending on the individual risk. Apixaban is also indicated for the treatment of venous thromboembolism but reimbursement has not yet been accepted in France for this indication. As with all direct oral anticoagulants, no routine biological monitoring is required, nevertheless their use may have an impact on all coagulation tests, eventually hampering interpretation. In particular clinical circumstances where a measure of anticoagulant efficacy is deemed necessary, specific assay of anti-Xa activity is appropriate, the result being expressed as concentration of the anticoagulant used. It is therefore necessary to state the name of the medicine for which the assay is requested. With these new anticoagulants, management of hemorrhagic events can be more difficult due to the lack of a specific antidote. Pro-hemostatic substances have exhibited efficacy in animal models but results are still insufficiently documented in clinical practice. Local or locoregional hemostasis measurements, when possible, are an essential factor in the treatment of hemorrhagic events.

The incidence and clinical predictors of ACE-inhibitor induced dry cough by perindopril in 27,492 patients with vascular disease.

OBJECTIVES: Our objective was to investigate the actual incidence and clinical determinants of cough leading to discontinuation of ACE-inhibitors. Cough is the most frequent reason to stop ACE-inhibitor treatment. METHODS: We studied 27,492 ACE-inhibitor naïve patients randomized to the ACE-inhibitor perindopril or placebo using individual data of 3 clinical trials. Multivariate logistic regression analysis was used to study the incidence of cough in relation to baseline clinical characteristics including racial background. RESULTS: In 27,492 patients with cardiovascular disease, 1076 patients discontinued ACE-inhibitor perindopril due to cough (3.9%), 703 patients during run-in period of 4 weeks and 373 patients during a mean four years of follow-up. Significant determinants of cough were female gender (OR 1.92 95% CI 1.68-2.18), age above 65 years (OR 1.53 95% CI 1.35-1.73), and concomitant use of lipid-lowering agents (OR 1.37; 95% CI 1.18-1.59). A simple clinical risk score composed of these 3 predictors of cough mounted to an odds ratio of 4.4 (95% CI 3.1-5.4) in the subjects with highest score (i.e. all determinants present). Racial background was not related to a differential incidence of cough in patients of Caucasian or Asian descendent (OR 1.11 95% CI 0.92-1.39). CONCLUSION: This large combined analysis of randomized clinical trials in 27,492 patients showed an overall lower incidence of cough leading to discontinuation of ACE-inhibitors (3.9%) as compared to literature. Clinical determinants of such cough are older age, female gender and concomitant use of lipid-lowering agents. In contrast, racial differences were not related to the incidence of cough.

[Correlation between urinary catecholamines dosage and apnea-hypopnea index in a hypertension population: pilot study]. / Corrélation entre les dosages des dérivés methoxylés urinaires et l'index d'apnée-hypopnée dans une population d'hypertendus : étude pilote.

AIMS: Sleep disorders like obstructive sleep apnea in adults are associated with increased sympathetic activity, which induced high blood pressure and could be associated with resistant hypertension. Some studies have demonstrated that high urinary catecholamine levels in obstructive sleep apnea patients may be decreased with continuous positive airway pressure therapy. However, very few studies have demonstrated a correlation between apnea-hypopnea index and urinary catecholamine levels in hypertension patients. METHODS: In this pilot study, 20 hypertensive patients referred for hypertension work-up including night-time polygraphy and 24h urinary catecholamine dosage were included. RESULTS: Mean age was 51±11 years (30-76), 68% were males. Diagnosis of obstructive sleep apnea was confirmed in 13 patients at the end of the work-up. Mean apnea-hypopnea index was 14±9 (2-32). The only urinary catecholamine parameter significantly increased in patients with obstructive sleep apnea was 24h urinary normetanephrine (1931±1285 vs 869±293nmol/24h; P<0.05). However, this difference was not significant when this parameter was adjusted to 24h urinary creatinine. We observed a significant positive correlation between AHI and 24h urinary normetanephine (r=0.486; P=0.035). CONCLUSION: This pilot study confirms an isolated elevation of 24h urinary normetanephrine in hypertensive patients with obstructive sleep apnea and shows a significant correlation between sleep disorders expressed by apnea-hypopnea index and urinary catecholamines excretion.

[Idiopathic retroperitoneal fibrosis: a multicentric retrospective study of 30 French cases and follow-up of the renal function]. / Fibrose rétropéritonéale idiopathique : évolution à long terme du pronostic rénal dans une série rétrospective multicentrique de 30 cas.

PURPOSE: Idiopathic retroperitoneal fibrosis (IRF) is an inflammatory disorder, affecting the aorta and the surrounding vessels and tissues. The prognosis is mainly driven by the risks of chronic kidney disease and relapse. Our aim was to assess the prevalence of chronic kidney disease at follow-up. METHODS: We retrospectively reviewed the medical records of patients diagnosed for IRF in Seine-Saint-Denis (France) between 1987 and 2011. We collected informations about presentation, radiologic findings and follow-up. Diagnosis of IRF was confirmed when all the following criteria were met: infiltration of the infrarenal aorta or iliac vessels, absence of aneurysmal dilation, lack of clinical suspicion of malignancy. RESULTS: Thirty patients were identified, with a male/female ratio of 4.9. Mean age was 55±13 years old. The mean creatinine clearance was 66 mL/min/1.73 m(2) and the mean CRP was 45±36 mg/L. In 24 (80%) patients, the location of IRF was periaortic and periiliac. Eleven patients (37%) underwent a diagnostic biopsy, and 14 (47%) required an ureteral procedure. A mean follow-up of 63 months was available for 29 patients: 69% relapsed, 7 developed chronic renal disease (24%), and one died of urinary sepsis. Older age (P=0.023), diabetes (P=0.007), and initial renal insufficiency (P=0.05) were associated with a risk of chronic renal insufficiency. CONCLUSION: The high frequency of relapses and chronic renal disease emphasizes the need of close follow-up in patients diagnosed with IRF.

[Flash Survey 2012: the use of self-measurement in France and its evolution since 2010]. / Enquête FLAHS 2012: la pratique de l'automesure tensionnelle en France et son évolution depuis 2010.

UNLABELLED: The objective of this investigation is to describe the characteristics of subjects with a self-measurement device, representative of the French population. METHODS: Auto four-page questionnaire administered by mail to 4500 individuals aged 35 years and over. RESULTS: Three thousand four hundred and sixty-two subjects aged 56 years responded to the questionnaire: 1054 subjects were treated hypertensives with a mean age 65.9 years and 2388 were untreated. Among treated subjects, 41% have one self-measurement blood pressure device (36% in 2010), 15% use one humeral device and 26% wrist device. Only 2% of treated hypertensive patients measure their blood pressure before a medical consultation, one times occasionally 49%, 11% several times a week, and 4% every day! Among 569 subjects owners of self-measure, 61% are treated hypertensive, 26% normotensive and 13% untreated hypertensive patients. Treated hypertensives are controlled with self-measurement in 50% of cases (BP<135 and 85 mmHg) (49% in 2010) CONCLUSIONS: In 2012, seven million of self-measurement devices are used in France, four million in treated hypertensives. Only 2% of hypertensive patients with self-measurement device use it correctly. Better education for hypertensive subjects is required. Control in hypertensive stagnated at 50%, incite to improve our therapeutic strategy, favoring pluritherapies.

[Trends in the use of antihypertensive drugs in France from 2002 to 2012: FLAHS surveys]. / Évolution dans l'usage des traitements antihypertenseurs en France entre 2002 et 2012: enquêtes FLAHS.

OBJECTIVE: To evaluate from studies conducted between 2002 and 2012, trends in the use of antihypertensive drugs in France. METHOD: French League Against Hypertension Survey (FLAHS) were conducted in a representative sample of subjects aged 35 and over living in France. A list including the names for all antihypertensive drugs marketed at the time of each survey made it possible to detail drug therapies employed. Data analysis has taken the patient as a unity. The data obtained in 2002, 2007 and 2012 are subject to this analysis. RESULTS: In 2012, 30% of the French population aged 35 and older was treated with antihypertensive drugs (11.4 million), while 24% were treated in 2002 (8.2 million). On average, prescription of antihypertensive included 1.4 ± 0.7 pills in 2002, 1.5 ± 0.8 in 2007 and 1.8 ± 0.9 in 2012, which corresponds to a pharmacological monotherapy prescribed in 47% of subjects in 2012, a different percentage than in 2007 (46%) and 2002 (56%). Over the period, the percentage of prescriptions of diuretics (41% to 42%) and ACE inhibitors (24% to 23%) and beta-blockers (35% to 36%) is stable, but they are increasing with ARBs (23% to 47%) and calcium antagonists (24% to 34%). The prescriptions of fixed-dose combinations were also increased (19% to 30%). In 2012, fixed-dose combinations included a diuretic (79%), an ARB (65%), an ACEI (23%) and a calcium antagonist (20%). Blood pressure control estimated with home blood pressure monitoring increases from 38% in 2002 to 50% in 2007 and 2012. CONCLUSION: Changes in the use of antihypertensive drugs in France between 2002 and 2012 led to the prescription of antihypertensive treatment with associations in the majority. ARBs or ACEI are present on 70% of prescriptions with diuretics combined in 80%. Extensive use of fixed-dose combinations with diuretics and ARA2 characterizes this period in which it was observed an increase in blood pressure control in France.

[Management of arterial hypertension in adults: 2013 guidelines of the French Society of Arterial Hypertension]. / Prise en charge de l'hypertension artérielle de l'adulte. Recommandations 2013 de la Société française d'hypertension artérielle.

To improve the management of hypertension in the French population, the French Society of Hypertension has decided to update the national guidelines with the following characteristics: usefulness for practice, synthetic form, good readability, comprehensive writing for non-doctors, emphasizing the role of patient education in the management of hypertension, wide dissemination to health professionals and the population of hypertensive subjects, impact assessment among health professionals and the public health goals. These guidelines include the following 15 recommendations, divided in three chapters, according to the timing of the medical management. BEFORE STARTING TREATMENT: 1. Confirm the diagnosis, with blood pressure measurements outside the doctor's office. 2. Implement lifestyle measures. 3. Conduct an initial assessment. 4. Arrange a dedicated information and hypertension announcement consultation. INITIAL TREATMENT PLAN (FIRST 6 MONTHS): 5. MAIN OBJECTIVE: control of blood pressure in the first 6 months (SBP: 130-139 and DBP<90 mmHg). 6. Favour the five classes of antihypertensive agents that have demonstrated prevention of cardiovascular complications in hypertensive patients. 7. Individualized choice of the first antihypertensive treatment, taking into account persistence. 8. Promote the use of (fixed) combination therapy in case of failure of monotherapy. 9. Monitor safety. LONG-TERM CARE PLAN: 10. Uncontrolled hypertension at 6 months despite appropriate triple-drug treatment should require specialist's opinion after assessment of compliance and confirmation of ambulatory hypertension. 11. In case of controlled hypertension, visits every 3 to 6 months. 12. Track poor adherence to antihypertensive therapy. 13. Promote and teach how to practice home blood pressure measurement. 14. After 80 years, change goal BP (SBP<150 mmHg) without exceeding three antihypertensive drugs. 15. After cardiovascular complication, treatment adjustment with maintenance of same blood pressure goal. We hope that a vast dissemination of these simple guidelines will help to improve hypertension control in the French population from 50 to 70 %, an objective expected to be achieved in 2015 in France.

Objective for 2015: 70% of treated and controlled hypertensive patients. Seven key points to reach this goal in practice. A joint call for action of the French League Against Hypertension and the French Society of Hypertension.

For the past 50 years, the implementation of therapeutic advances to the largest number of people has made it possible to have an exemplary reduction in cardiovascular mortality, contributing to extension of life expectancy observed in France. Nevertheless, such gains are fragile, and largely dependent on the quality of blood pressure control. The relative stagnation of blood pressure control in France for the last 5 years is potentially one of its early markers. The French League against Hypertension and the French Society of Hypertension, with the support of the French Ministry of Health, have decided to combine their efforts to provide a new impetus to management of this disease and to make blood pressure control a priority. An ambitious improvement of the percentage of controlled hypertensive patients from 50% to 70% in 2015 is targeted. To achieve this goal, a simplified decisional algorithm is proposed: seven key points dedicated to general practice are emphasized.

Protease inhibitor treatment effect on aortic stiffness in normotensive patients with human immunodeficiency virus infection.

OBJECTIVES: Human immunodeficiency virus (HIV) infection and protease inhibitor (PI)-based antiretroviral treatment might increase large artery (aortic) stiffness compared with healthy untreated controls. To clarify the role of PI therapy in the progression of subclinical arteriosclerosis in patients with HIV, we investigated the impact of PI treatment on arterial stiffness. METHODS AND RESULTS: In our single-centre, cross-sectional study, normotensive male HIV patients free from overt cardiovascular disease received PI treatment (n=60) or no PI treatment (n=42). The PI group had a significantly higher pulse wave velocity (PWV) than the PI-free group (9.0 ± 1.4 vs. 8.1 ± 1.3m/s; P=0.016). There was a significant positive correlation between age and PWV in the PI-free group (R(2) 0.310; P<0.0001) and, to a lesser extent, in the PI group (R(2) 0.181; P<0.0001). PI treatment was associated with a significant increase in the adjusted slope of the curve relating age to PWV as compared with no PI treatment. CONCLUSIONS: In normotensive HIV patients, PI treatment significantly increases both aortic stiffness and the positive correlation between PWV and age. Aortic stiffness predicts cardiovascular mortality, thus these results provide new insight on the relationship between PI treatment, mechanical arteriosclerotic and cardiovascular risk.

[Use of antihypertensive drugs in France and relationship with cardiovascular disease. FLAHS 2009-2010 surveys]. / Utilisation des traitements antihypertenseurs en France et relations avec les pathologies cardiovasculaires. Enquêtes FLAHS 2009-2010.

OBJECTIVE: Describe how antihypertensive drugs are prescribed in France in 2009 and 2010 and assess the effect of the presence of cardiovascular disease on the characteristics of the treatment. METHODS: The French League Against Hypertension Surveys (FLAHS) are conducted among a representative sample of individuals aged 35 years and older living in France. For the 2009 and 2010 surveys, a sample of 2292 subjects who declared to take one or more antihypertensive drug has been studied. In addition to the details of antihypertensive medications taken the day of the survey, the personal history for cardiovascular diseases was compiled. RESULTS: Of the 2292 prescriptions with at least one antihypertensive prescription frequencies are: ARB (43%), diuretics (43%), beta-blockers (34%), CCB (26%), ACEI (26%), spironolactone (8%), central and alpha (7%), DRI (1%). The prescription is performed as monotherapy (42%), bitherapy (37%), triple therapy (16%) and quadruple or more (5%). When triple therapy is prescribed, there is an association ACEI or ARB or DRI+Diu+BB in 46%, and an association ACEI or ARB or DRI+Diu+AC in 30%. Cardiovascular disease is present or past reported by 24% of hypertensive patients: coronary artery disease (13%), heart failure (6%), arrhythmias (5%), stroke (4%), PAD (4%). The use of BB is more common in hypertensive patients who have coronary artery disease, heart failure and arrhythmia. ACE inhibitors are more common in hypertensive patients with coronary artery disease, heart failure or stroke. CCB are more frequent in cases of coronary artery disease or PAD. The ARB are less frequent in patients with coronary artery disease. CONCLUSION: The ARB, diuretics and beta-blockers are the most prescribed antihypertensives in France in 2009 to 2010. Cardiovascular diseases declared in 24% of hypertensives led to a preferential prescription of an ACE inhibitor or BB.

Limbic encephalitis and type 1 diabetes with glutamic acid decarboxylase 65 (GAD65) autoimmunity: improvement with high-dose intravenous immunoglobulin therapy.

Glutamic acid decarboxylase antibodies (GAD-abs) are an immunological factor involved in type 1 diabetes and other diseases involving the central nervous system. This report is of a patient with type 1 diabetes and a rare case of non-paraneoplastic limbic encephalitis mediated by anti-GAD65 antibodies that improved with the use of immunosuppressive drugs.

[Hypertension and cardiovascular risk: the J-curve concept]. / Hypertension artérielle et risque cardiovasculaire: l'hypothèse de la courbe en J.

The optimization of the pharmacologic treatment in hypertensive patients is encouraged by four reports: the high prevalence of hypertension and more particularly in the elderly, the lack of blood pressure control in more than half of patients, the frequency of the association to other cardiovascular risk factors and the existence of a residual risk under treatment. All these factors are combined to raise the cardiovascular risk in hypertensive patients. Several interventional studies highlighted a reduction of the cardiovascular risk proportional to the reduction of blood pressure under treatment. Thus arose the question of the optimal blood pressure: the guidelines propose values lower than 140/90 mmHg for the non-complicated essential hypertension and lower than 130/80 mmHg in secondary prevention, for the patients with diabetes or renal impairment. However, this strict blood pressure goal for the high cardiovascular risk patients is not confirmed by clinical trials, strict blood pressure goal being potentially deleterious. The concept of «the lower the better¼ tends to be abandoned. Since more than three decades, the assumption of a paradoxical increase of the cardiovascular morbidity and mortality associated with a high reduction of blood pressure (the «J-Curve¼ concept) remains the subject of many studies and controversies.