Blood pressure targets: How low should you go (and for whom)?

Say “goodbye” to prehypertension; say “hello” to elevated BP

The 2017 ACC/AHA guideline changed the BP classification for adults (TABLE 1^1,2). While “normal” remained respectively.¹ Removal of the “prehypertension” category and use of the term “elevated” instead was meant to better convey the importance of lifestyle interventions to forestall the development of hypertension.

Don’t underestimate the power of BP measurement technique

The importance of appropriate BP measurement technique to confirm a hypertension diagnosis and assist with medication titration is emphasized in the ACC/AHA guidelines.

The importance of appropriate BP measurement technique to confirm the diagnosis of hypertension and assist with medication titration was also emphasized.¹ BP measurement technique in usual clinical practice is frequently suboptimal, most commonly resulting in falsely elevated readings.^9,10 The guideline recommends the use of out-of-office measurements to confirm elevated clinic readings, screen for white-coat and masked hypertension, and assist in medication adjustment decisions. It is critically important that appropriate BP measurement technique is used, which in many cases, will avoid inappropriate treatment. (See “Getting the hypertension Dx right: Patient positioning matters,” JFP. 2018;67:199-207.)

A look at the evidence supporting lower BP goals

The 2017 ACC/AHA guideline recommends a BP goal <130/80 mm Hg for adults with hypertension commonly seen in clinical practice, including those with CVD or an elevated ASCVD risk (10-year risk ≥10% using the Pooled Cohort Equations¹¹), those with hypertension and low ASCVD risk (10-year risk <10%), and those with hypertension who have concomitant diabetes or CKD.¹ The guideline also recommends an SBP goal <130 mm Hg for independently-living, ambulatory older adults (≥65 years) with hypertension.¹ TABLE 2^1,2,6 compares the BP goals in the new 2017 ACC/AHA guidelines to previous recommendations.

SPRINT. Significant new literature has been generated since the publication of JNC 8 that supports these lower BP goals, particularly in patients with CVD or who are at high ASCVD risk.^8,12-15 For example, the Systolic Blood Pressure Intervention Trial (SPRINT) was the largest RCT to assess whether lower BP goals decrease the risk of adverse CVD outcomes.¹⁶ In SPRINT, 9361 patients with an SBP ≥130 mm Hg and an increased risk of CVD, but without diabetes or a history of stroke, were randomized to intensive BP treatment (SBP goal <120 mm Hg) or standard treatment (SBP goal <140 mm Hg). After a median follow-up of 3.26 years, the study was stopped early due to a decreased risk in the primary composite outcome of myocardial infarction (MI), other acute coronary syndromes (ACS), stroke, heart failure, or death from CV causes (number needed to treat [NNT] to prevent one event=61).

Intensive treatment was also associated with a lower risk of all-cause mortality (NNT=90), heart failure (NNT=123), death from CV causes (NNT=172), and the primary outcome or death (NNT=52). While hypotension was higher in the intensive treatment group (number needed to harm [NNH]=106), as was syncope (NNH=173), electrolyte abnormalities (NNH=126), and acute kidney injury or failure (NNH=61), the authors noted that the benefits of lower BP outweighed the risks. Also, there was no increased risk of injurious falls. Therefore, despite the risk of adverse events, SPRINT demonstrated that lower BP goals significantly reduce the risk of adverse CV outcomes.

Continue to: Meta-analyses that have been conducted since SPRINT...