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“Go Low” or “Say No” to Aggressive Systolic BP Goals?

The SPRINT trial demonstrated the benefits—and risks—of reaching a systolic target < 120 mm Hg in nondiabetic patients at high risk for cardiovascular events. Here’s who might benefit.

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PRACTICE CHANGER
Consider treating nondiabetic patients ages 50 and older to a systolic blood pressure (SBP) target < 120 mm Hg (as compared to < 140 mm Hg) when the benefits—lower rates of fatal and nonfatal cardiovascular (CV) events and death from any cause—are likely to outweigh the risks from possible additional medication.1

Strength of Recommendation
B: Based on a single, good-quality randomized controlled trial (RCT). 1

A 55-year-old man with hypertension and stage 3 chronic kidney disease (CKD) presents for routine care. His blood pressure is 135/85 mm Hg, and he is currently taking lisinopril 40 mg/d. Should you increase his antihypertensive ­regimen?

Hypertension is common and leads to significant morbidity and mortality, but pharmacologic treatment reduces incidence of stroke by 35% to 40%, myocardial infarction (MI) by 15% to 25%, and heart failure by up to ­64%.­2-4 Specific blood pressure targets for defined populations continue to be studied.

The ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial found that more intensive BP targets did not reduce the rate of major CV events in patients with diabetes, but the study may have been underpowered.5 The members of the Eighth Joint National Committee (JNC 8) recommended treating patients older than 60 to BP goals < 150/90 mm Hg.6 This was based on evidence from six RCTs, but there remains debate—even among the JNC 8 committee members—as to appropriate BP goals in patients of any age without CV disease who have BP measurements of 140-159/90-99 mm Hg. 7-13

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