We thank Alberto Morales-Salinas for his interest in our article1 on the new European guidelines for hypertension.2 We fully agree that the scientific evidence on most of the aspects concerning grade 1 hypertension and low cardiovascular risk is scarce and that this situation will probably continue because prospective placebo-controlled studies are unlikely to be performed to evaluate the effects of treatment on mid- and long-term morbidity and mortality in this type of patient. This lack of evidence affects and will continue to affect both lifestyle-related interventions and antihypertensive drug therapy. Thus, we have no other option but to continue basing our therapeutic decisions on the limited evidence available and to apply it on an individualized basis to our patients according to their clinical characteristics, a fact mentioned by Morales-Salinas and emphasized by the European guidelines.

In these times of precision, personalized, and preventive medicine, treatment initiation at early stages of the hypertensive process is the most logical approach, given that an intervention delay permits progression of hypertension and is associated with residual risk after blood pressure normalization. For patients with grade 1 hypertension and low cardiovascular risk, the recommended strategy is to lower blood pressure through lifestyle changes for a period of up to 6 months. This approach is advised because these patients’ values are very close to normal, although more than half are overweight and have a sedentary lifestyle, and because modest weight loss via a better diet and regular physical exercise can normalize blood pressure. Nonetheless, the intervention must also be personalized according to the socioeconomic characteristics of the population.

The European guidelines aim to be a general rule based on the best available evidence from controlled clinical trials and their meta-analyses. Because the patients included in these studies are often dissimilar to those seen in the clinic, we should individualize the guidelines by weighing up the pros and cons of our decisions with the patient. However, the responsibility for clinical decisions always lies with the physician treating the patient.