Current recommended goals for treatment of hypertension

What are the current recommended goals for treatment of hypertension?

BP treatment goals are controversial despite the recent publication of a trial intended to bring clarity to the issue. By way of background, although epidemiologic data indicate that a BP <115/75 mm Hg is associated with the lowest risk of cardiovascular morbidity and mortality, several studies have suggested that “lower BP” is not necessarily better to prevent cardiovascular events. The traditional BP target of <140/90 mm Hg for all patients with hypertension was lowered to a target of <130/80 mm Hg in patients with diabetes, people with chronic kidney disease (CKD), or those with established heart disease, but recent guidelines have not suggested special BP goal for these groups. Relatively few outcome-based clinical trials have been performed that randomized subjects with hypertension to different BP targets. One of the exceptions is the Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD-BP) Trial, which showed no significant benefit in patients with hypertension and diabetes randomly assigned to a systolic BP target of <120 mm Hg except for the secondary endpoint of stroke.

Another prominent trial that randomized patients to different BP goals was the Systolic Blood Pressure Intervention Trial (SPRINT). SPRINT enrolled over 9000 hypertensive patients at least 50 years of age and randomized them to intensive BP-lowering (goal systolic BP 120 mm Hg) or less intensive BP-lowering treatment (goal systolic BP 140 mm Hg). SPRINT excluded patients with diabetes or prior stroke. The trial was halted before scheduled completion after the Data Safety Monitoring Board revealed a 25% lower risk of fatal and nonfatal major cardiovascular events and death from any cause in the intensive BP-lowering arm. On the other hand, adverse events were more common with intensive treatment. SPRINT’s generalizability has come into question because of the use of unattended automated office BPs in the trial to measure the achieved BP, which was the primary intervention in the trial. The precise correlation of BP measured this way with BP measured in others ways is unclear, although the findings should be applicable to patients who matched the enrollment criteria and whose BP is measured using a similar method.

In November 2017 the American Heart Association (AHA) and American College of Cardiology published the Clinical Practice Guideline for Hypertension. This redefined hypertension as follows:

  • • Normal: systolic BP (SBP) <120 mm Hg AND diastolic BP (DBP) <80 mm Hg
  • • Elevated: SBP 120–129 mm Hg AND DBP <80 mm Hg
  • • Stage 1 hypertension: SBP 130–139 mm Hg OR DBP 80–89 mm Hg
  • • Stage 2 hypertension: SBP ≥140 mm Hg OR DBP ≥90 mm Hg

Treatment decisions are based on individual patients’ cardiovascular risk. For patients with diabetes, known cardiovascular disease, or more than a 10% risk of an atherosclerotic event in the next 10 years the guideline recommends treating if the BP >130/80 with a treatment goal of a blood pressure below 130/80.

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