Evidence for a lower target blood pressure for people with heart disease

Abstract

The review assesses the evidence for the benefit of lower blood pressure (BP) targets in hypertension management. The current consensus target for the treatment of hypertension is a BP of below 140/90 mmHg for all patients, and a BP of below 130/80 mmHg for those with diabetes or chronic kidney disease. Recently added to the list of conditions warranting the lower BP target are coronary artery disease and coronary artery disease equivalents (stroke, carotid disease, aortic aneurysm, and peripheral vascular disease), as well as those individuals with a Framingham Risk Score of at least 10%. One theoretical issue with lower BP targets may be the existence of a J-shaped curve of BP versus cardiovascular event rate, implying a greater risk, especially of myocardial ischemia, of lowering diastolic BP, which is also the filling pressure of the coronary arteries, below the lower limit of coronary autoregulation. The evidence that this is not a compelling concern is provided by animal studies, clinical trials with both surrogate and hard endpoints, and epidemiologic data. There is at present no proof that more aggressive treatment is harmful and much indirect evidence that it may be beneficial, although the clinical trials that specifically address this question are still in progress.