Chronic hypertension medical therapy blood pressure goals of treatment
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Lakshmi Gopalakrishnan , M.D.; Arzu Kalayci, M.D. [2]
The 24-hour ambulatory systolic pressure may better predict mortality than the daytime systolic blood pressure.[1]
Regarding the accuracy of office oscillometric and home blood pressure monitoring compared with ambulatory blood pressure monitoring, a meta-analysis by the Rational Clinical Examination found[2]:
- Office pressures (presumably attended by medical personnel) has sensitivity and specificity of 51% and 88%
- Home monitoring has sensitivity and specificity of 75% and 76%
Clinical practice guidelines
Recommendations for treatment goals from recent clinical practice guidelines are tabulated below. However, treated based on underlying risk rather than a blood pressure target may be more effective[3]. The logic supporting a target of 130/80 mm Hg has been disputed[4] and the Cochrane Collaboration found insufficient evidence to determine a treatment goal for adults[5] or adults over 65 years of age[6].
If the goal is 130/80, proper measurement includes (distilled from Table 8 of the ACC/AHA guidelines[7], executive summary[8]):
- having the patient sit quietly for 5 minutes before a reading is taken
- supporting the limb used to measure BP
- ensuring the BP cuff is at heart level
- using the correct cuff size
- for auscultatory readings, deflating the cuff slowly
- the timing of BP measurements in relation to ingestion of the patient’s medication should be standardized
- a single reading is inadequate for clinical decision-making. An average of 2 to 3 BP measurements obtained on 2 to 3 separate occasions will minimize random error and provide a more accurate basis for estimation of BP.
If the above measurement methods are not use, a preliminary study from Kaiser Northern California suggests a target of 140 mm Hg[9].
| Clinic (routine)
AHA, 2017[7] |
Clinic (routine)
Roerecke, 2018[10] |
Clinic (automated)
Roerecke, 2018[10] |
Home (self)
AHA, 2017 |
Daytime, ambulatory † | Nighttime ambulatory
AHA, 2017[7] |
24 hour ambulatory[10] |
|---|---|---|---|---|---|---|
| 120/80 | 125/82 | 120/80 | 120/80 | 120/80 | 100/65 | 115/75 |
| 130/80 | 145/85 | 130/80 | 130/80 | 130/80 | 110/65 | 125/75 |
| 140/90 | 150/90 | 135/85 | 135/85 | 135/85 | 120/70 | 130/80 |
| 160/100 | 160/95 | 145/90 | 145/90 | 145/90 | 140/85 | 145/90 |
| Notes: † Benegas found that the 24-hour ambulatory systolic pressure may better predict mortality than the daytime systolic blood pressure.[1] | ||||||
| Goal < 60 years old | Goal >= 60 years old | High risk | |
|---|---|---|---|
| JNC-8, 2014[12] | 140/90 | 150/90* | |
| ACP/AAFP, 2017[11] | Not applicable | 150 or 140 if high risk | |
| HEDIS and MIPS QI Measures | < 140/90 | ||
| Kaiser, 2019[13] | 140/90 | Kaiser states "In adults with ASCVD, CKD, age > 75 years, or 10-year ASCVD risk > 10%, consider treating to a goal SBP of < 130 mm Hg" This is consistent with more agressive treatment in the SPRINT trial[14]. | |
| AHA/ACC/others, 2017[8] | < 130/80† | ||
| * Treat to 140/90 if age >=60 with DMII or CKD.
† Treat if > 140/90 or 130/80 if high risk which is defined as existing cardiovascular disease, 10-year cardiovascular risk ≥10%, diabetes, or CKD. | |||
Newer trials
Newer randomized controlled trials have identified conflicting benefits to more intensive therapy.
| Patients | BP target in intervention | Final BP in intervention | Primary outcome (composite) (Hazard ratio) | |||
|---|---|---|---|---|---|---|
| Baseline blood pressure | Estimated cardiac risk (calculated with pooled cohort equation) |
Outcome rate in the control | ||||
| ACCORD, 2010[15] | 140/76 | All patients were diabetic 9% for anglo women and 23% for anglo men |
2.1% per year | SBP 120 vs 140 | 119/64 | 0.88 (95% CI: 0.73 to 1.06) |
| SPRINT, 2015[14] | 140/78 | No diabetics 16% for anglo women and 23% for anglo men (20% overall) |
2.2% per year | SBP 120 vs 140 | 121/67 | 0.75 (95% CI: 0.64 to 0.89) |
| HOPE-3, 2016[16] | 138/82 | 16% for anglo women and 23% for anglo men | 1.7% per year* | No target BP. Intervention all received candesartan 16 mg per day plus hydrochlorothiazide 12.5 mg per day |
128/76 | 0.93 (95% CI: 0.79 to 1.10) |
Notes:
* 1.7% is the sum of the two co-primary outcomes. The HOPE-3 also reported 4.4% over 5.6 years. | ||||||
- In the ACCORD (Action to Control Cardiovascular Risk in Diabetes) randomized controlled trial patients with average blood pressure of 140/76 mm Hg and diabetes did not benefit from targeting a systolic blood pressure of less than 120 mm Hg (average 119/64 mm Hg), as compared with less than 140 mm Hg.[15]
- Assuming the average patient in this trial was a nonsmoker and was diabetic, the estimated 10-year cardiovascular risk is 9% for anglo women and 23% for anglo men.
- In the SPRINT randomized control trial, patients with an average blood pressure of 140/78 mm Hg and at high risk for CVD but who do not have a history of stroke or diabetes, intensive BP control (target SBP <120 mm Hg) that lowered systolic blood pressure to an average of 121/67 mm Hg improved CV outcomes and overall survival compared to standard therapy, while modestly increasing the risk of some serious adverse events[14].
- Assuming the average patient in this trial was not diabetic, 50% were smokers (per their publication)), 33% were women, and LDL was 113 (per their publication Friedrwald estimate is 191 - 53 - 125/5)) the estimated 10-year cardiovascular risk is 12% for anglo women and 20% for anglo men.
- The number needed to treat (NNT), is about 200 (185) for the primary outcome (1.65% vs 2.19%) by dropping the systolic pressure by 15 mm Hg.
- In the HOPE-3 trial randomized controlled trial, patients with an average blood pressure of 138/82 mm HG and with intermediate risk who did not have cardiovascular disease lowering systolic blood pressure to an average of 128 mm Hg was insignificantly beneficial. [16]
- Assuming the average patients in this trial was a nonsmoker and not diabetic, the estimated 10-year cardiovascular risk is 10% for anglo women and 19% for anglo men.
- Benefit was found in a subgroup analysis of patients with systolic blood pressure above 144 mm Hg (mean 154 mm Hg).
Debate exists on how low should physicians target blood pressure in their patients especially in light of studies that have shown a J or U-shaped curve phenomenon associated with hypertension treatment where low and very high blood pressure values are associated with increased risk of cardiovascular events.[17] A less strict target in diabetic and elderly patients is in the new ADA and ESH/ESC 2013 clinical practice guidelines respectively. This rationale is supported by the fact that lower SBP targets in diabetic patients have not been shown to generate better outcomes.[18] Similarly, treatment of stage 1 hypertension in elderly patients and targeting SBP values to <140 mmHg have not been well substantiated and may sometimes carry more risk than benefit.[19]
References
- ↑ 1.0 1.1 Banegas JR, Ruilope LM, de la Sierra A, Vinyoles E, Gorostidi M, de la Cruz JJ; et al. (2018). "Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality". N Engl J Med. 378 (16): 1509–1520. doi:10.1056/NEJMoa1712231. PMID 29669232. Review in: BMJ Evid Based Med. 2019 Jun;24(3):114-115
- ↑ Viera, Anthony J.; Yano, Yuichiro; Lin, Feng-Chang; Simel, David L.; Yun, Jonathan; Dave, Gaurav; Von Holle, Ann; Viera, Laura A.; Shimbo, Daichi; Hardy, Shakia T.; Donahue, Katrina E.; Hinderliter, Alan; Voisin, Christiane E.; Jonas, Daniel E. (2021). "Does This Adult Patient Have Hypertension?". JAMA. 326 (4): 339. doi:10.1001/jama.2021.4533. ISSN 0098-7484.
- ↑ Blood Pressure Lowering Treatment Trialists' Collaboration (2014). "Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data". Lancet. 384 (9943): 591–598. doi:10.1016/S0140-6736(14)61212-5. PMID 25131978. Review in: Ann Intern Med. 2014 Dec 16;161(12):JC5 Review in: Evid Based Med. 2015 Feb;20(1):21
- ↑ Wilt TJ, Kansagara D, Qaseem A, Clinical Guidelines Committee of the American College of Physicians (2018). "Hypertension Limbo: Balancing Benefits, Harms, and Patient Preferences Before We Lower the Bar on Blood Pressure". Ann Intern Med. 168 (5): 369–370. doi:10.7326/M17-3293. PMID 29357397.
- ↑ Saiz LC, Gorricho J, Garjón J, Celaya MC, Erviti J, Leache L (2018). "Blood pressure targets for the treatment of people with hypertension and cardiovascular disease". Cochrane Database Syst Rev. 7: CD010315. doi:10.1002/14651858.CD010315.pub3. PMID 30027631.
- ↑ Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM (2017). "Blood pressure targets for hypertension in older adults". Cochrane Database Syst Rev. 8: CD011575. doi:10.1002/14651858.CD011575.pub2. PMID 28787537.
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C; et al. (2017). "2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Hypertension. doi:10.1161/HYP.0000000000000065. PMID 29133356.
- ↑ 8.0 8.1 8.2 Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C; et al. (2017). "2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Hypertension. doi:10.1161/HYP.0000000000000066. PMID 29133354.
- ↑ Go AS (2018). "Impact of SPRINT-Based Blood Pressure Levels on Clinical Outcomes in a Large, Community-Based Population: The Kaiser Permanente Experience". Circulation. doi:10.1161/circ.136.suppl_1.14468.
- ↑ 10.0 10.1 10.2 10.3 Roerecke M, Kaczorowski J, Myers MG (2019). "Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension: A Systematic Review and Meta-analysis". JAMA Intern Med. 179 (3): 351–362. doi:10.1001/jamainternmed.2018.6551. PMC 6439707. PMID 30715088.
- ↑ 11.0 11.1 Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA; et al. (2017). "Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians". Ann Intern Med. 166 (6): 430–437. doi:10.7326/M16-1785. PMID 28135725. Review in: Ann Intern Med. 2017 Apr 18;166(8):JC38
- ↑ 12.0 12.1 James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J; et al. (2014). "2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8)". JAMA. 311 (5): 507–20. doi:10.1001/jama.2013.284427. PMID 24352797.
- ↑ Kaiser (2019). Adult Blood Pressure. Available at http://kpcmi.org/how-we-work/guidelines/
- ↑ 14.0 14.1 14.2 SPRINT Research . Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM; et al. (2015). "A Randomized Trial of Intensive versus Standard Blood-Pressure Control". N Engl J Med. 373 (22): 2103–16. doi:10.1056/NEJMoa1511939. PMC 4689591. PMID 26551272.
- ↑ 15.0 15.1 ACCORD Study . Cushman WC, Evans GW, Byington RP, Goff DC, Grimm RH; et al. (2010). "Effects of intensive blood-pressure control in type 2 diabetes mellitus". N Engl J Med. 362 (17): 1575–85. doi:10.1056/NEJMoa1001286. PMC 4123215. PMID 20228401. Review in: Evid Based Med. 2010 Oct;15(5):142-3 Review in: Ann Intern Med. 2010 Jul 20;153(2):JC1-4, JC1-5
- ↑ 16.0 16.1 Yusuf S, Lonn E, Pais P, Bosch J, López-Jaramillo P, Zhu J; et al. (2016). "Blood-Pressure and Cholesterol Lowering in Persons without Cardiovascular Disease". N Engl J Med. 374 (21): 2032–43. doi:10.1056/NEJMoa1600177. PMID 27039945.
- ↑ Bangalore S, Messerli FH, Wun CC, Zuckerman AL, DeMicco D, Kostis JB; et al. (2010). "J-curve revisited: An analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial". Eur Heart J. 31 (23): 2897–908. doi:10.1093/eurheartj/ehq328. PMID 20846991.
- ↑ "Summary of revisions for the 2013 clinical practice recommendations". Diabetes Care. 36 Suppl 1: S3. 2013. doi:10.2337/dc13-S003. PMC 3537268. PMID 23264423.
- ↑ Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M; et al. (2013). "2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension". J Hypertens. 31 (10): 1925–38. doi:10.1097/HJH.0b013e328364ca4c. PMID 24107724.