Blood pressure targets: How low should you go (and for whom)?
The ACC/AHA's lower BP goals are supported by previously unavailable evidence, the strongest of which is for patients with CVD. But others can benefit, too.
PRACTICE RECOMMENDATIONS
› Treat adults with hypertension and cardiovascular disease or those at high risk (≥10%) of an atherosclerotic cardiovascular disease (ASCVD) event to a blood pressure (BP) goal <130/80 mm Hg. A for systolic BP goal; C for diastolic BP goal.
› Treat adults with hypertension and a low risk of a cardiovascular event (ie, primary prevention and ASCVD <10%) to a BP goal <130/80 mm Hg. B for systolic BP goal; C for diastolic BP goal.
› Treat ambulatory, community-dwelling, noninstitutionalized older patients to a systolic BP goal <130 mm Hg. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
In recent meta-analyses assessing the effects of intensive BP lowering on renal and CV events in patients with CKD, a lower BP strategy was not associated with a decrease in CV events.8,14,19 However, more intensive therapy was associated with a 17% reduced risk of composite kidney failure events and an 18% reduction in end-stage kidney disease.19 The risk of kidney failure with lower BP goals was 27% lower in patients with baseline proteinuria, but was not significant in patients who did not have proteinuria.19
Evidence supports lower BP goals, but guidelines should guide
The lower BP goals advised in the 2017 ACC/AHA guideline are supported by substantial new high-quality evidence that was not available at the time of the JNC 8 report.1 The strongest evidence for lower goals is found in patients with, or at high risk for, CVD, but other patients commonly seen by primary care providers, including those at lower CVD risk, older patients, and those with diabetes or CKD are also likely to benefit.1
Despite the debates, it is important to remember that guidelines are intended to “guide.” As stated in the guideline, “Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.”1 They should be easy to understand and apply, and a consistent, evidence-based BP goal of <130/80 mm Hg for most patients facilitates implementation.
Although more of the US population is categorized as hypertensive under the new guideline (46% now vs 32% before), only 1.9% more require drug therapy, as the vast majority of the newly classified hypertensives are primary prevention patients for whom only lifestyle modification is recommended.37 However, to attain these goals, greater emphasis will be needed on utilizing team-based care, health information technology including electronic medical records and telehealth, performance measures, quality improvement strategies, and financial incentives.1
Finally, as emphasized in the guidelines, BP monitoring technique matters. Clinicians should not accept flawed BP measurement techniques any more than they would accept flawed results from studies performed incorrectly.
CORRESPONDENCE
Eric J. MacLaughlin, PharmD, BCPS, FASHP, FCCP, Texas Tech University Health Sciences Center,1300 S. Coulter Dr., Amarillo, TX 79106; Eric.MacLaughlin@ttuhsc.edu.
ACKNOWLEDGEMENTS
The authors thank Paul K. Whelton, MB, MD, MSc, FAHA, and Robert M. Carey, MD, FAHA, for their review of this manuscript.
