- It's a very interesting statistic that in people who have diabetes, having also hypertension means the same cardiovascular risk factors as in people who already had a myocardial infarction [heart attack].

- Right! That's one of the old studies that showed that the risk of [heart attack and stroke] in patients with diabetes is much higher than the general population, and once you have diabetes, in some sense it is "secondary prevention", which means that it's like someone who already has had myocardial function. Because the risk is so high that it is the same as the risk of someone who had myocardial infarction. That's why not all guidelines say the same, but in some guidelines diabetic patients require treatment with aspirin and cholesterol-lowering medications, like those who had myocardial infraction in the past. It's also very interesting that when we talk about blood pressure we talk about differences in blood pressure goals of 10 millimeters of mercury and a lot of people say, well, plus or minus 10 units of blood pressure measurement is actually not that much, but it turns out it means a lot! It's very important, of course, when you take the individual person, it's not the same as if you take a million people and you see what is the difference in the events when the blood pressure is lowered by 10 millimeters of mercury. Each 20 millimeters of mercury in the systolic blood pressure and 10 millimeters of mercury in the diastolic blood pressure doubled the risk [of heart attack and stroke] If you see a patient with 115 systolic blood pressure, then someone with 195 - 80 mm Hg blood pressure difference increases the risk by tenfold, which is huge. So it's very clear that blood pressure difference of 10 millimeters of mercury counts. Now for the person himself it may be different, but when you take the average, you take the epidemiology of many people, you understand that each millimeter of mercury [in blood pressure] counts. So there is no such thing as non meaningful difference in blood pressure. Of course, people should really try to achieve the blood pressure goals in treatment that are assigned to their category of risk... The point is that the trend is not the same - when you go down from 180 to 160, the 20 millimeters of mercury difference gives you a very significant reduction in events [heart attack and stroke] but when you go from 140 to 120, now you get less benefit, so that the difference about 20 millimeters of mercury depends on from what you start to where you go. And of course that's why we say, OK, if you go to 140, the most of the benefit you've already achieved by reduction from 180 to 140 [systolic blood pressure] Now, the question is what is the additional benefit from lowering from 140 to 130? Let's say that there is an additional benefit, but it's low, and then you say how much you have to pay for it - not in money - but in side effects of medications? And then you have to wait and see if it's worthwhile to try and lower the blood pressure 10 millimeters more and expose the patients to side effects, etc. So this is personalized medicine - that's the difference between doing a large study on million people or a few hundreds thousands of people - but when you treat a [specific] patient, you have to balance the benefits versus the disadvantages [side effects] And that's why hypertension treatment guidelines are so complicated, there is a lot of room for personalized decisions that physician might take.. No question! The guidelines give you just a direction, but whether you want to go through this direction to reach the goal - it depends on the physician, it also depends on the patient himself - you have to explain to the patient what is the situation, what may be the side effects, what is the benefit and then patient decides [on treatment]