Having read the interesting letter from Graciano et al,1 we would like to comment on a number of considerations.

First, we feel that, to understand trends and identify areas for improvement, it is imperative that physicians analyze how we prescribe. However, we consider that it is not enough to analyze the number of prescriptions for antihypertensive drugs without putting the issue in the appropriate clinical context. In principle, the increase in prescriptions for antihypertensive agents in recent years is, in itself, neither good nor bad. We believe this increase should have been correlated in some way with the blood pressure control achieved over this period, as well as with the incidences of stroke and ischemic heart disease.

In our opinion, there are many reasons for the prescription of more antihypertensive drugs, which include not only population aging (hypertension is more common among elderly patients), but also the greater prevalence of hypertension among young people due to their unhealthy lifestyle habits. This alone would explain the higher number of prescriptions. Fortunately, however, physicians are increasingly aware of the importance of reducing blood pressure to the recommended target levels, including in those patients with mild hypertension. Although clinical trials have been unable to clearly demonstrate any clinical benefits of antihypertensive therapy in patients with mild hypertension,2 the mean follow-up in these studies was only 2 to 5 years, too short a period to demonstrate benefits in this population. However, these patients will evidently experience more events in the long-term than other individuals of the same age with normal blood pressure.

The data from the PRESCAP study show that, over the last decade, hypertension control has improved in Spain, mainly due to more widespread use of combined therapy and to less therapeutic inertia.3,4 This has taken place not only in Spain, but also in other western European countries and the United States.5 Even more importantly, the increased use of combination therapy has reduced the number of cardiovascular events.6

Where we are in complete agreement with the authors is in that, in Spain, there is still a great deal of room for improvement in blood pressure control. Therefore, although the prescription of antihypertensive drugs has increased in recent years, this rise is probably still insufficient (or the doses used) if what we really want is to achieve acceptable hypertension control in Spain and, as a secondary objective, ensure that our hypertensive patients have fewer cardiovascular complications.