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Every 5 to 6 years, international and national guidelines provide updated recommendations for the standard management of hypertension in adults. Thus, within the last 18 months, societies from Europe (European Society of Cardiology and European Society of Hypertension), America (American College of Cardiology and American Heart Association), and Great Britain (National Institute for Health and Care Excellence) published their new guidelines. Despite the fact that all of them are supposedly based on the most recent clinical evidence, there are always some discrepancies between recommendations due to different interpretation of clinical trials. The purpose of the present review is to discuss 6 issues that have generated some controversies, namely, the definition of hypertension, identification of patients who should be treated, target blood pressure, pertinence of reducing salt intake, mono- or combination therapy as first-line treatment, and the role of renal denervation in resistant hypertension.

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A precise maintenance of sodium and fluid balance is an essential step in the regulation of blood pressure and alterations of this balance may lead to the development of hypertension. In recent years, several new advances were made in our understanding of the interaction between sodium and blood pressure regulation. The first is the discovery made possible with by new technology, such as 23Na-MRI, that sodium can be stored non-osmotically in tissues including the skin and muscles particularly when subjects are on a high sodium diet or have a reduced renal capacity to excrete sodium. These observations prompted the refinement of the original model of regulation of sodium balance from a two-compartment model comprising the extracellular fluid within the intravascular and interstitial spaces to a three-compartment model that includes the intracellular space of some tissues, most prominently the skin. In this new model, the immune system plays a role, thereby supporting many previous studies indicating that the immune system is a crucial co-contributor to the maintenance of hypertension through pro-hypertensive effects in the kidney, vasculature, and brain. Lastly, there is now evidence that sodium can affect the gut microbiome, and induce pro-inflammatory and immune responses, which might contribute to the development of salt-sensitive hypertension.

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Blood pressure (BP) is routinely measured as a vital sign before, during and/or after dialysis (peridialysis BP). Even if peridialytic measurements are widely used, the agreement with the interdialytic BP is poor and is often biased by many technical errors [1]. Since accurate BP measurements are critical for making decisions and evaluating a patient’s cardiovascular risk, Working Groups from the ERA-EDTA and the European Society of Hypertension (ESH) issued recommendations on standardized BP measurement in dialysis patients [2]. Previous studies have underlined substantial differences between recommendations for BP measurement in general and effective BP measurements performed by medical staff [3], but whether these recommendations are followed in dialysis centres has not been investigated so far. The objectives of this multi-centric, cross-sectional survey were (i) to assess the adherence to current recommendations [4] on BP measurements in dialysis centres both according to physicians’ and patients’ perspectives and (ii) to evaluate the use of out-of-office BP measurements in dialysis patients.

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The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a wellrecognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

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I n high-income countries, ≈1 in 4 adults have an elevated blood pressure (BP), when defined as an office BP >140/90 mmHg.1,2 In the United States, this prevalence reaches 40% in blacks and >60% in adults >60 years of age2 with the same definition. High BP put these individuals at greater risk of developing hypertension-mediated organ damages or dying prematurely from a cardiovascular event. During the last decades, many initiatives and campaigns have been set up to increase the awareness and the control of hypertension in the population. The last example is the May Measurement Month 2017, during which BP was measured in >1.2 million unselected adults around the world. This campaign showed that 17.3% of participants with an elevated BP were not treated and 46.3% of those receiving treatment did not have a well-controlled BP. Yet, in contrast to these disappointing results, several surveys have demonstrated very positive trends in terms of global cardiovascular protection. These include a decrease in age-standardized BP over years in high-income countries,1 a positive trend in age-adjusted percentage of controlled hypertension among treated US adults with an increase from 31.6% in 2000 to 53.9% in 2014,2 and a constant decrease in cardiac death in the US population during the last 40 years. Of course, this latter observation cannot be attributed to a better control of BP only. It rather reflects the benefits of the global efforts made to reduce the impact of major cardiovascular risk factors, that is, smoking, high cholesterol levels, diabetes mellitus, overweight, and high BP.

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Preeclampsia is a hypertensive disorder specific to gestation that affects 5% to 8% of all pregnancies1 and is associated with a greater lifetime risk for cardiovascular and renal complications.2,3 Recently, different international guidelines have underlined that women who had a hypertensive disorder of the pregnancy should benefit from a postpartum screening and management for cardiovascular risk factors, but with no precise recommendations, especially about the timing of the first medical visit.4–7 The existence and the prevalence of specific hypertensive phenotypes after preeclampsia is not known and the place of ambulatory blood pressure monitoring (ABPM) in the early follow-up of preeclampsia needs to be defined.

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Hypertension and chronic kidney disease (CKD) are global health issues [1] with a strong cause and effect relationship [2]. Both hypertension and CKD are associated with a high risk of cardiovascular (CV) morbidity and mortality [3]. Hypertension together with proteinuria contributes to the progression of CKD [4,5], resulting in an increased CV and all-cause mortality [6,7]. Blood pressure (BP) control in patients with CKD reduces the likelihood of progression to end-stage renal disease (ESRD) and the occurrence of CV events [8]. Therefore, guidelines recommend a target BP of 140/ 90 mmHg with careful monitoring of adverse events (AEs) in CKD patients with proteinuria <1 g24 h and lower targets in those with proteinuria>1 g/24 h [9–11]. Most recently, the 2017 American College of Cardiology/American Heart Association (ACC/AHA) clinical practice guidelines recommended an aggressive BP goal of <130>

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The kidney has long been placed at the very center of extracellular volume, sodium (Naþ) and blood pressure (BP) homeostasis. Recently, Titze et al. [1] suggested that the skin and muscle also contribute to the regulation of sodium balance in humans. In a long-term Mars flight simulation study, they reported that healthy male individuals accumulated Naþ in considerable amounts without concomitant weight gain, in contrast to the generally accepted theory that changes in total body sodium are paralleled by changes in extracellular volume [2]. They stated that Naþ can accumulate in the skin and muscles where it is stored without being osmotically active, bound to negatively charged glycosaminoglycans, and representing thus a third compartment of storage which is regulated by the immune system [3].

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Today non-communicable (NCD) diseases account for almost 70% of deaths around the World and among them, about one half are due to cardiovascular diseases [1]. Together with tobacco smoking and unhealthy food, hypertension remains one of the leading cause of non-communicable diseases in developed countries, although blood pressure (BP) levels tend to decrease in high-income countries. In contrast, in low-income countries, BP and its burden on health increase continuously [2]. Blood pressure is known to increase with age [3]. Hence, it is not surprising that the prevalence of hypertension is highest in subjects older than 60 years. Thus, in the updated estimates for the prevalence and control of hypertension in the United States for 2015–2016, the prevalence of hypertension was 63% among all adults older than 60 years with a greater percentage in women (66.8%) than in men (58.5%) [3]. Today, a normotensive individual reaching the age of 65 years has a 90% lifetime risk of developing hypertension if she/he lives a further 20 to 25 years [4].

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High-sodium intake and low-potassium intake are known dietary risk factors for arterial hypertension (AH) [1–3]. High-potassium intake reduces blood pressure (BP) and the risk of stroke [4]. Data regarding their role in cardiovascular morbidity and mortality are more controversial. In the US The National Health and Nutrition Examination Survey (NHANES) study, sodium intake and sodium-to-potassium intake ratio estimated by 24-h dietary recalls were associated with higher all-cause and cardiovascular mortality, whereas potassium intake appeared to be protective, with the strongest predictive value for the sodium-to-potassium intake ratio [5]. In the Prospective Urban Rural Epidemiology study, a large worldwide study, similar results were obtained using the Kawasaki formula to estimate 24-h urinary sodium and potassium excretions [3]. A similar association with cardiovascular events was found by using sodium-to-potassium excretion ratio in 24-h urine [6]. On the contrary, some studies rather showed an increase in mortality with lower sodium intake either at population or more recently at a community level [7,8].

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