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  • Before addressing point by point the aforementioned topics i


    Before addressing point-by-point the aforementioned topics in separate sub-sections it should be remarked that the strength of recommendations provided by guidelines is graded in three classes: I (evidence and/or general agreement that a given treatment or procedure is beneficial, useful,effective), II (conflicting evidence and/or divergence of opinion about the usefulness/efficacy of the given treatment or procedure), III (evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful). The recommendations are further classified according to different levels of evidence: A (data derived from multiple randomized trials or meta-analysis), B (data derived from single randomized clinical trial or large non-randomized studies), C (consensus or opinion of the experts and/or small studies, registries).
    BP targets Two distinct BP targets, namely 140/90mmHg in low-moderate risk hypertensives and <130/80mmHg in high-risk hypertensives (i.e. subjects with diabetes, cerebrovascular, cardiovascular, or renal disease) were suggested by the 2007 ESH/ESC guidelines [5]. A re-appraisal of some of these recommendations has been made by current guidelines [6] on the basis of a an extensive review of randomized controlled trials that indicated there are no solid data supporting to lower BP to <130/80mmHg in patients with diabetes or a history of cardiovascular or renal disease. A systolic BP target lower than 140mmHg is currently recommended in hypertensive patients with different clinical characteristics: low-moderate cardiovascular risk (class I, level B), ezh2 pathway (class I, level A), previous stroke or ischemic transient attack, coronary heart disease, chronic kidney disease (class II, level B) and in fit elderly subjects aged <80years (class II, level C). Systolic BP values between 150 and 140mmHg are recommended in elderly hypertensives regardless of age, provided they are in good physical and mental conditions. Whereas, in the frail elderly population systolic BP goals should be adapted to individual tolerability. As for diastolic BP, a target of <90mmHg is recommended in all patients, except in those with diabetes, in whom treatment optimization requires diastolic BP to be lowered to <85mmHg. These indications of the guidelines regarding the target pressure seems to mediate two concepts widely debated in the last decades: 1) the lower the BP achieved by the treatment the better the outcome; 2) the hypothesis of a J-shaped relationship, according to which the total benefit of reducing BP to markedly low values are lower than for reductions to more moderate values [8], [9]. Deserves mention the fact that the BP goals proposed by the guidelines refer to the pressure measured in the medical environment as no direct evidence from randomized outcome studies is yet available about BP targets when home or 24h ambulatory BP measurements are adopted [10]. In addition to the recommendations on BP target, the 2013 ESH/ESC guidelines emphasize the concept that the protective effects of antihypertensive therapy depend not only on the BP levels achieved during treatment but also on the persistence of BP control between on-treatment visits. The first report about the clinical and prognostic role ezh2 pathway of variability visit–visit relates to hypertensive patients with coronary heart disease in which the positive effect of therapy was directly related to increasing percentage of visits with office BP at target [11]. Ten years later this remark, a meta-analysis, including a total of 23 high-quality cohort studies with 107,434 hypertensive patients, expanded the notion that the visit-to-visit variability is a strong predictor of fatal and non-fatal cardiovascular complications [12].
    Lifestyle changes The usual salt intake is between 9 and 12g/day in many Westernized communities and it has been shown that reduction to about 5–6g/day has a marginal (1–2mmHg) systolic BP-lowering effect in normotensive people and a somewhat more evident effect (4–5mmHg) in hypertensive subjects [13], [14]. A reduction in dietary sodium to 80–100mml (about 5g of salt) is thus recommended for the general population [15]. It has been shown that the effects of sodium reduction may vary widely in relation to individual ethnic and demographic characteristics being more greater in black people, older people and in individuals with diabetes, metabolic syndrome or chronic kidney disease.