Blood Pressure Limbo-How Low Can You Go?

Abstract

Hypertension is one of the leading causes of death worldwide (1). In 2019, 20.3% of all adult female deaths and 18.2% of all adult male deaths were attributed to high systolic blood pressure (SBP) globally (1). Population-based surveys from diverse settings have shown that many adults with high blood pressure (BP) are not appropriately diagnosed (2). This represents a failure of health systems, particularly when it is known that BP-lowering medications significantly reduce cardiovascular disease (CVD) events among hypertensive patients (3). Furthermore, those patients who are diagnosed are nonetheless often undertreated and not at the recommended BP target. Recent guidelines recommend lower BP targets than ever before, resulting in an increasingly urgent need to address the widespread undertreatment of hypertension. For people on BP-lowering medication, the 2017 American College of Cardiology/American Heart Association guidelines for hypertension recommend targeting a BP goal of <130/80 mmHg for all hypertensive patients including patients with diabetes (4). The 2018 European Society of Cardiology guidelines recommend targeting a BP of <130/80 mmHg in most treated patients, as long as such treatment is well tolerated, and targeting an SBP in the range of 120–129 mmHg in patients <65 years of age (5). These more intensive treatment recommendations were informed by randomized clinical trial (RCT) data (6) but also by a wealth of epidemiologic data (7). However, the data informing BP targets for patients with diabetes are somewhat mixed, which contributed to the 2021 American Diabetes Association recommendation to use a CVD risk calculator prior to determining the appropriate BP target for individuals with diabetes. A target of <130/80 mmHg is reserved for patients with a 10-year CVD risk of ≥15%, while a target of <140/90 mmHg is advised for individuals at lower risk (8). These different guideline recommendations reflect the ongoing uncertainty in the balance …