Applied Evidence

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

Department of Pharmacy Practice, Texas Tech University Health Sciences Center (TTUHSC) School of Pharmacy (Drs. MacLaughlin and Young); Department of Family and Community Medicine (Drs. MacLaughlin, Slaton, and Young) and Department of Internal Medicine (Dr. MacLaughlin), TTUHSC School of Medicine, Amarillo, Tex; PinnacleHealth CardioVascular Institute, Wormleysburg, Pa (Dr. DePalma); Director of Regulatory and Professional Practice, American Academy of Physician Assistants, Alexandria, Va (Dr. DePalma)

Drs. MacLaughlin and DePalma were members of the Guideline Writing Committee for the 2017 American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. This manuscript does not reflect the views or opinions of the Guideline Writing Committee.

Drs. Slaton and Young reported no potential conflict of interest relevant to this article.



Treating older patients

Significant controversy has existed regarding the optimal BP goal in older patients, particularly once the JNC 8 recommended relaxing the SBP goal to <150 mm Hg for pateints ≥60 years of age.6,7 This recommendation was consistent with the guideline from the American College of Physicians (ACP)/AAFP,26 which also recommended a lower SBP of <140 mm Hg in patients with a history of stroke or transient ischemic attack and those at high CV risk.26

A 20-mm Hg increase in SBP above 115 mm Hg is associated with an approximate doubling of stroke and ischemic heart disease mortality risk.

Evidence is available, however, supporting more intensive BP goals in older independently-living ambulatory adults. A pre-planned subgroup analysis was conducted in 2636 SPRINT participants ≥75 years of age.27 Similar to the overall experience in SPRINT, lower SBP goals were associated with significant reductions in CV events, including the composite CVD primary outcome (NNT=27), heart failure (NNT=63), nonfatal heart failure (NNT=66), and all-cause mortality (NNT=41). In addition, the relative benefits were approximately equal whether the patients were the most fit, non-fit, or frail, with the absolute benefit being greatest in those who were frail (recognizing that the SPRINT participants were independently-living ambulatory adults). While the absolute rate of serious adverse events was higher in the more intensive BP goal group, there was no statistically significant difference in the incidence of hypotension, orthostatic hypotension, syncope, electrolyte abnormalities, or acute kidney injury or renal failure.

Use of lower BP goals than recommended by JNC 8 was also supported by another recent meta-analysis that compared the outcomes of intensive BP lowering (SBP <140 mm Hg) to a standard BP-lowering strategy (SBP <150 mm Hg).18 Using a random-effects model, more intensive BP lowering was associated with a significant reduction in major adverse CV events (29%), CV mortality (33%), and heart failure (37%), with no increase in serious adverse events or renal failure. Findings with the fixed-effects model used to confirm results were largely consistent, with the exception of a possible increase in renal failure.

Although the evidence supporting lower BP goals in older, ambulatory, noninstitutionalized patients is sound, it is important to consider a patient’s overall disease burden. For older adults with multiple comorbidities and limited life expectancy, as well as those who are nonambulatory or institutionalized, decisions on the intensity of BP lowering should be made using a team-based approach, weighing the risks and benefits.1

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