Blood pressure treatment goals

What are the blood pressure treatment goals?

The optimal blood pressure level for a patient is controversial. The panel that convened for the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) published recommendations in early 2014. The members limited themselves to review only randomized, controlled trials. JNC 8 published a number of controversial recommendations:

  • • Patients with diabetes and chronic kidney disease, the goal clinic blood pressure changed from <130/80 mm Hg to <140/90 mm Hg, as results from trials such as the ACCORD, REIN-2, AASK, and MDRD did not reveal that lower clinic blood pressures improved outcomes in these groups.
  • • Based upon trials such as the HYVET, Syst-Eur, and SHEP, patients ≥60 years without diabetes mellitus or chronic kidney disease achieve a goal clinic blood pressure <150/90 mm Hg, while those <60 years achieve a blood pressure <140/90 mm Hg.

Many experts found this last recommendation troubling, as they felt it predisposed high-risk patients (e.g., older African Americans with hypertension) to lax blood pressure control and increased cardiovascular risk over time. Most international guidelines recommend changing the 60-year-old cut-off to 80 years of age or older.

In November of 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) published joint guidelines for the diagnosis and management of hypertension. The following terms were defined based on clinic blood pressures obtained in a standardized manner:

  • • Normal blood pressure: systolic pressure <120 mm Hg, diastolic pressure is <80 mm Hg
  • • Elevated blood pressure: systolic pressure 120 to 129 mm Hg, and diastolic pressure is <80 mm Hg
  • • Stage 1 hypertension: systolic blood pressure of 130 to 139 mm Hg, or a diastolic blood pressure of 80 to 89 mm Hg
  • • Stage 2 hypertension: systolic blood pressure ≥140 mm Hg, or a diastolic blood pressure of ≥90 mm Hg

All patients should receive nonpharmacological therapy if they have elevated clinic blood pressures, stage 1 hypertension, or stage 2 hypertension. Those patients with ≥10 % risk of developing atherosclerotic cardiovascular disease over 10 years ( http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/ ) or with known cardiovascular disease should be treated pharmacologically if they have stage 1 hypertension. All patients, regardless of cardiovascular disease status, should receive pharmacological therapy if they have stage 2 hypertension.

The SPRINT trial called attention to the way blood pressure is measured. Automated office blood pressure monitoring was employed in the SPRINT trial by using the Omron HEM-907 device. The study protocol mandated that patients sit quietly for five minutes prior to the machine taking three measurements at one-minute intervals. The blood pressure measurements were then averaged. The trial randomized three groups of hypertensive patients ≥50 years at high risk for cardiovascular events:

  • 1. Chronic kidney disease patients
  • 2. Patients with known cardiovascular disease with an estimated 10-year Framingham risk score >15%
  • 3. Patients with ≥75 years

The two blood pressure targets were either a systolic blood pressure <120 mm Hg or <140 mm Hg. The intensively treated group achieved a systolic blood pressure of 121.5 mm Hg, whereas the control group achieved a systolic blood pressure of 134.6 mm Hg. After a little more than three years of follow-up, the trial was stopped prematurely because of a 25% relative risk reduction among the intensive group in the primary endpoint. The primary endpoint was a combination of cardiovascular outcomes including cardiovascular mortality. Furthermore, a 27% relative risk reduction in all-cause mortality was seen. When interpreting the SPRINT results, one must be cautious not to directly compare these data to other hypertension trials that obtained clinic blood pressures using either oscillometric or mercury cuffs operated by medical personnel without the mandated period of five minutes of seated rest. Thus applying either the JNC 8 or the ACC/AHA recommendations in a post-SPRINT world becomes problematic. Automated office blood pressures generally run 5 to 10 mm Hg lower than traditionally obtained clinic blood pressures. The Canadian Hypertension Education Program now recommends that the cutoff for diagnosing hypertension by automated office blood pressure monitoring be <135/85 mm Hg, instead of <140/90 mm Hg. However, it is unlikely that an algebraic manipulation alone will be useful for individual level decision-making.

Out-of-office blood pressures are also generally lower than traditional clinic blood pressures. Recent ambulatory blood pressure thresholds have been published:

For awake ambulatory blood pressures:

  • • For men without high-risk disease, the goal blood pressure is <135/85 mm Hg
  • • For women without high-risk disease, the goal blood pressure is <125/80 mm Hg
  • • For hypertensive patients with diabetes or chronic kidney disease, the goal blood pressure is <120/75 mm Hg

For home blood pressures the American Heart Association recommends

  • • Hypertensive patients without high-risk disease a blood pressure goal of <135/85 mm Hg
  • • Diabetic and chronic kidney disease patients with hypertension a blood pressure goal of <130/80 mm Hg
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