Recent insights in the development of organ damage caused by hypertension

Recent recommendations for the management of hypertension have stressed the importance of assessing subclinical target organ damage for the evaluation of cardiovascular risk, the choice of anti hypertensive treatment and the follow-up of hypertensive patients. In addition to classic hallmarks of target organ damage (left ventricular hypertrophy, renal dysfunction, microalbuminuria), new concepts emerging from basic research and technical progresses have allowed more accurate and earlier detection of target organ damage affecting the heart (plasma BNP, coronary calcifications), the brain (silent lacunar infarcts, advanced deep white matter lesions, microbleedings) and the vasculature. The latter include markers of diffuse atherosclerosis (carotid intima-media thickness), arterial stiffness (pulse wave velocity, augmentation index) and endothelial dysfunction (increased plasma levels of adhesion molecules). Current studies should help to better define the predictive power of these new phenotypes for the occurrence of overt cardio- and cerebrovascular diseases, their reversibility under anti hypertensive treatment and the most adapted therapeutic strategy in at-risk patients. Furthermore, early identification of hypertensive patients more likely to develop target organ damage, will be facilitated by a more global evaluation of cardiovascular risk factors, a better use and wider acceptance of ambulatory BP measurement (including determination of nocturnal dip and blood pressure variability) and, maybe, an increased knowledge of the genetic factors underlying susceptibility to target organ damage. Lastly, randomized studies comparing different classes of antihypertensive drugs should help to test the well-known but frequently challenged concept of additional benefits of some anti hypertensive drugs "beyond BP" on prevention and reversal of target organ damage.