High blood pressure and albuminuria, both therapeutic targets for cardiovascular disease protection?

High blood pressure is associated with high cardiovascular (CV) risk, and lowering it is associated with risk reduction. Recently, albuminuria has been associated with increased CV risk. This association was explained by albuminuria being the consequence of CV disease rather than the cause. Thus, efforts to explain CV protective effects of new drugs by their ability to lower albuminuria were largely discarded. However, throughout the recent decades many new therapeutic approaches showed that the individual degree of reduction of albuminuria predicts the individual degree of CV protection irrespective of the intervention used (low protein diet, ACE-inhibitors, AII-antagonists, endothelin antagonist or even SGLT2-inhibitors) and irrespective of the underlying disease (healthy population, CV risk population, diabetes, chronic kidney disease of varying origin). Should one conclude that albuminuria should be aggressively reduced under the motto ‘the lower the better’ (just like blood pressure). Further studies showed the issue to be much more complex. Both blood pressure lowering as well as albuminuria lowering by itself showed to be beneficial in one individual and had no or even bad effects in other individuals. This led to discovery and creation of a therapy response score as a better CV protection predictor. It showed a picture that was similar to the discovery of CV risk scores: a combination of the different risk markers gives a much better CV risk prediction than any risk factor by itself. Logically, drugs targeted to lower a single risk factor may not effectively predict CV protection, since it depends on the composite effect of the drug on all risk factors (be it a fall in one but a rise in another). Today we are dealing with a new world in which CV risk is determined not only by high blood pressure or albuminuria, but by a host of different risk factors. CV protection thus needs a multiparameter approach improving all of them. This is best shown by the very recent studies with SGLT-2 inhibitors, which have glucose lowering as their registered target, but may also lower blood pressure, albuminuria, and even body weight! Interestingly, CV protection of this class appears overwhelming in all kinds of different diseases. Thus, drugs or combinations of drugs should not have single targets but should be tailored to the risk profile and response profile of each individual person. The time for true Personalized Medicine in cardiovascular disease treatment has clearly arrived.