Blood Pressure Treatment Targets Research Articles

Blood Pressure Treatment Targets in Adults Aged 60 Years or Older.

The editorialists discuss the hypertension guidelines from the American College of Physicians and American Academy of Family Physicians. They provide advice for implementation of an office-based pr...

Strict blood pressure control associates with decreased mortality risk by APOL1 genotype

Although APOL1 high-risk genotype partially accounts for the increased susceptibility of blacks to chronic kidney disease (CKD), whether APOL1 associates differentially with mortality risk remains controversial. Here we evaluate the association between APOL1 genotype and risk of death and determine whether APOL1 status modifies the association between strict versus usual blood pressure control and mortality risk. We performed a retrospective analysis of the African American Study of Kidney Disease and Hypertension trial that randomized black participants with CKD to strict versus usual blood pressure control from 1995 to 2001. This included 682 participants with known APOL1 genotype (157 with high-risk genotype) previously assigned to either strict (mean arterial pressure [MAP] 92 mmHg or less) versus usual blood pressure control (MAP 102-107 mmHg) during the trial. During a median follow-up of 14.5 years, risk of death did not differ between individuals with high- versus low-risk APOL1 genotypes (unadjusted hazard ratio 1.00 [95% confidence interval 0.76-1.33]). However, a significant interaction was detected between the APOL1 risk group and blood pressure control strategy. In the APOL1 high-risk group, the risk of death was 42% lower comparing strict versus usual blood pressure control (0.58 [0.35-0.97]). In the APOL1 low-risk group, the risk of death comparing strict versus usual blood pressure control was not significantly different (1.09 [0.84-1.43]). Thus, strict blood pressure control during CKD associates with a lower risk of death in blacks with the high-risk CKD APOL1 genotype. Knowledge of APOL1 status could inform selection of blood pressure treatment targets in black CKD patients.

The Implications of Blood Pressure Measurement Methods on Treatment Targets for Blood Pressure.

Over the past 45 years, a number of clinical outcome trials have evaluated the effects of blood pressure (BP) reduction on cardiovascular outcomes.1 Most recently, SPRINT (Systolic Blood Pressure Intervention Trial) randomly assigned 9361 persons with a systolic blood pressure (SBP) of ≥130 mm Hg and increased cardiovascular risk to a SBP target <120 mm Hg versus <140 mm Hg. Although the results of SPRINT provide evidence that the goal SBP should be closer to 120 than 140 mm Hg, the methods of BP measurement were notably different between this trial and many others. More important, the methodology for measuring BP in SPRINT is not what is used in most clinical practices, and this difference has significant clinical implications. Most cardiovascular outcome trials, to date, have used either ausculatory or automatic oscillometric methods of seated BP measurement performed shortly after the patient’s arrival for a visit, with similar methods currently used in most clinical practices. The SPRINT methodology is not in widespread use clinically; BP was measured after the participant sat quietly alone for 5 minutes, after which study personnel returned to the room to measure BP 3 times at 1-minute intervals with all 3 values averaged. BP recorded in research studies using the standard BP …

Why in 2016 are patients with hypertension not 100% controlled? A call to action.

The objective is to consider the problem of high blood pressure (BP), a leading global risk factor, associated with substantial morbidity and mortality. Despite the availability of treatment guidelines and a wide range of therapies, BP control is suboptimal in many countries. Recent data indicate that only around 40% of patients manage to achieve an adequate level of BP control. A group of international experts in the field of hypertension met in 2008 to consider this problem. The resulting white paper delivered an urgent call to action and identified six key issues for improving BP control. In 2015, a working group of investigators spontaneously undertook an action with the primary aim of considering the current hypertension management situation in Europe, to discuss whether the situation had changed since 2008 and to determine what can be learnt from the projects in other continents, such as the Canadian Hypertension Education Program, which has shown that higher levels of BP control can be achieved across a general population. The working group identified the main challenges affecting the improvement of BP control today and suggests five key actions: identify the BP treatment target of less than 140/90 mmHg for the majority of patients, simplify treatment strategies and encourage pill reduction, decrease therapeutic inertia, improve patient empowerment, and involve healthcare systems and reduce the prevailing focus on drug costs in many healthcare systems. Implementing key actions identified by the working group may help to improve achievement of better BP control across Europe.

National Diabetes Foot Care Audit results: initial steps identify areas of current need

National Diabetes Foot Care Audit results: initial steps identify areas of current need

Review of the Systolic Blood Pressure Intervention Trial for Hypertension Management: How Low to Go for Patients With Stroke?

One of the great successes of modern medicine is the development of effective pharmacological treatments to lower blood pressure (BP). Of the modifiable risk factors for cardiovascular disease, elevated BP or hypertension has the highest population attributable risk,1 and a near continuous relationship with rates of stroke and coronary heart disease from levels of 115 mm Hg systolic and 75 mm Hg diastolic BP.2 Overviews of randomized trials are consistent in showing that lowering systolic BP by 5 to 10 mm Hg reduces the risk of stroke by one third, irrespective of disease history, initial BP level, or type of agent used.3–5 Moreover, more intensive long-term BP lowering can result in additional benefits proportional to the size of fall in BP.4–6 Despite this body of evidence, there has been longstanding controversy (and consternation) over the levels to which BP should be brought down by treatment for the prevention of cardiovascular disease. Because there has been limited randomized evidence, guideline committees have been challenged in defining BP targets below 130 to 140 mm Hg to manage individual patients.7 Concerns over diminishing net benefit being overtaking by excessive harm with increasing reductions in BP is supported by a physiological argument over critical thresholds for organ perfusion and secondary analysis of randomized trials suggesting a J-shaped relationship with cardiovascular events.8 Moreover, recent trials of more intensive BP lowering, including the Action to Control Cardiovascular Risk on Type 2 Diabetes (ACCORD)9 and Secondary Prevention of Small Subcortical Strokes (SPS3),10 failed to show significant reductions in rates of ischemic stroke with systolic BP reductions below 120 and 130 mm Hg, respectively. The main result of the Systolic …

Unobserved automated office blood pressure measurement in the Systolic Blood Pressure Intervention Trial (SPRINT): systolic blood pressure treatment target remains below 140 mmHg

The Systolic Blood Pressure Intervention Trial (SPRINT) enrolled 9300 participants age 50 years and older without diabetes or previous stroke in ∼100 expert medical centres and clinical practices throughout the USA.1 Between 2010 and 2013, the SPRINT investigators randomly allocated the study participants into a standard treatment group receiving an average of two different blood pressure (BP) medications to achieve a systolic BP (SBP) target of <140 mmHg, and an intensive treatment group receiving an average of three BP medications to achieve an SBP target of <120 mm Hg. SPRINT was stopped early because of effect. The target SBP of <120 mmHg had reduced rates of the composite primary outcome that included myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes by 25% and the risk of death from all causes by 27%, as compared with the target SBP of <140 mmHg.2 However, …

Systolic BP Targets Should Probably Be Higher in Early Aortic Stenosis

ORLANDO — Optimal blood pressure in patients with asymptomatic mild to moderate aortic stenosis is 140–159 mm Hg for systolic and 70–89 mm Hg for diastolic, according to an analysis of all-cause mortality in the world's largest data set of such patients with longitudinal follow-up and endpoint evaluation. Within those target blood pressure ranges, the nadir in terms of all-cause mortality is about 145/82 mm Hg, Kristian Wachtell, MD, PhD, reported at the American Heart Association scientific sessions. He presented an analysis of 1,873 asymptomatic patients with mild to moderate aortic stenosis (AS) and a peak aortic-jet velocity of 2.5–4.0 m/s upon enrollment in the Simvastatin Ezetimibe in Aortic Stenosis (SEAS) trial. SEAS was a double-blind, multicenter study in which participants were randomized to 40 mg of simvastatin plus 10 mg of ezetimibe per day or placebo and followed for a mean of 4.3 years. Half of them had a history of hypertension at baseline. As previously reported (N Engl J Med 2008;359:1343–56), SEAS was a negative trial. Lipid-lowering therapy didn't affect AS progression or aortic valve–related outcomes. On the plus side, the SEAS cohort is the world's largest population of patients with asymptomatic AS followed prospectively for clinical endpoints, noted Dr. Wachtell of Oslo University. 'I think it's most likely that for blood pressure, one size does not fit all. ... The extent of target organ damage ... warrants a different level of blood pressure.' He and his coinvestigators decided to plot all-cause mortality vs. average blood pressure in the SEAS cohort because of the paucity of data regarding blood pressure and antihypertensive therapy in patients with asymptomatic AS. Neither the 2014 ACC/AHA guidelines for management of valvular heart disease (Circulation 2014;129[23]:e521–643) nor the European guidelines provide recommendations for optimal blood pressure targets in patients with asymptomatic AS, even though AS is the third most common cardiac disease, behind hypertension and coronary artery disease. Moreover, nearly 100,000 aortic valve replacements are done per year in the United States as a consequence of AS. And AS and hypertension go hand in hand, with the prevalence of hypertension among patients with AS cited as 50% or more in multiple studies, the cardiologist continued. In a multivariate analysis adjusted for aortic valve area index and peak velocity, heart failure, myocardial infarction, and aortic valve replacement during follow-up, all-cause mortality showed a U-shaped relationship with blood pressure. A systolic blood pressure below 120 mm Hg was associated with a 5-fold increased risk of mortality, a systolic of 120–139 mm Hg carried a 1.5-fold increased risk, and a diastolic blood pressure of 90 mm Hg or more was associated with a 1.9-fold increased risk. “Patients with low systolic blood pressure had an increased mortality risk and should probably undertake individual clinical assessment for blood pressure control and evaluation of their AS,” Dr. Wachtell said. The first question audience members asked was, “What about SPRINT?” The SPRINT trial, presented elsewhere at the meeting, was a practice-changing study that was the talk of the conference. It redefined the systolic blood pressure treatment target as less than 120 mm Hg instead of less than 140 mm Hg in hypertensive patients (N Engl J Med 2015;373:2103–16). “I think it's most likely that for blood pressure, one size does not fit all,” Dr. Wachtell replied. “The extent of target organ damage — and you could say that aortic stenosis is actually target organ damage, like atrial fibrillation or left ventricular hypertrophy — warrants a different level of blood pressure.” He added, however, that the SEAS analysis was based on observational data, and that's a limitation. “This is a qualified guess as to what blood pressures should be in patients with aortic stenosis,” he cautioned. Dr. Wachtell reported having no conflicts of interest regarding his presentation. Bruce Jancinis with the Denver bureau of Frontline Medical News.

Lower blood pressure targets: to whom do they apply?

For many decades, the optimum blood pressure treatment target to prevent cardiovascular disease has been debated. Until 2013, most guidelines suggested that the general population with hypertension should be treated to achieve a blood pressure goal of lower than 140/90 mm Hg, but that the goal for some high-risk groups, such as patients with diabetes and chronic kidney disease, should be a blood pressure of lower than 130/80 mm Hg. In 2013, most guidelines relaxed the recommendations for high-risk patients, based on a lack of evidence, which was brought to attention after the disappointing results of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. 1 Mancia G Fagard R Narkiewicz K et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013; 31: 1281-1357 Crossref PubMed Scopus (4059) Google Scholar , 2 James PA Oparil S Carter BL et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the eighth Joint National Committee (JNC 8). JAMA. 2014; 311: 507-520 Crossref PubMed Scopus (5873) Google Scholar , 3 Cushman WC Evans GW Byington RP et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010; 362: 1575-1585 Crossref PubMed Scopus (2746) Google Scholar Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysisIntensive blood pressure lowering provided greater vascular protection than standard regimens. In high-risk patients, there are additional benefits from more intensive blood pressure lowering, including for those with systolic blood pressure below 140 mmHg. The net absolute benefits of intensive blood pressure lowering in high-risk individuals are large. Full-Text PDF

What is the evidence base for diagnosing hypertension and for subsequent blood pressure treatment targets in the prevention of cardiovascular disease?

Diagnosing and treating hypertension plays an important role in minimising the risk of cardiovascular disease and stroke. Early and accurate diagnosis of hypertension, as well as regular monitoring, is essential to meet treatment targets. In this article, current recommendations for the screening and diagnosis of hypertension are reviewed. The evidence for treatment targets specified in contemporary guidelines is evaluated and recommendations from the USA, Canada, Europe and the UK are compared. Finally, consideration is given as to how diagnosis and management of hypertension might develop in the future.

Effects of benchmarking on the quality of type 2 diabetes care: results of the OPTIMISE (Optimal Type 2 Diabetes Management Including Benchmarking and Standard Treatment) study in Greece.

To investigate the effect of benchmarking on the quality of type 2 diabetes (T2DM) care in Greece. The OPTIMISE (Optimal Type 2 Diabetes Management Including Benchmarking and Standard Treatment) study [ClinicalTrials.gov identifier: NCT00681850] was an international multicenter, prospective cohort study. It included physicians randomized 3:1 to either receive benchmarking for glycated hemoglobin (HbA1c), systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-C) treatment targets (benchmarking group) or not (control group). The proportions of patients achieving the targets of the above-mentioned parameters were compared between groups after 12 months of treatment. Also, the proportions of patients achieving those targets at 12 months were compared with baseline in the benchmarking group. In the Greek region, the OPTIMISE study included 797 adults with T2DM (570 in the benchmarking group). At month 12 the proportion of patients within the predefined targets for SBP and LDL-C was greater in the benchmarking compared with the control group (50.6 versus 35.8%, and 45.3 versus 36.1%, respectively). However, these differences were not statistically significant. No difference between groups was noted in the percentage of patients achieving the predefined target for HbA1c. At month 12 the increase in the percentage of patients achieving all three targets was greater in the benchmarking (5.9-15.0%) than in the control group (2.7-8.1%). In the benchmarking group more patients were on target regarding SBP (50.6% versus 29.8%), LDL-C (45.3% versus 31.3%) and HbA1c (63.8% versus 51.2%) at 12 months compared with baseline (p < 0.001 for all comparisons). Benchmarking may comprise a promising tool for improving the quality of T2DM care. Nevertheless, target achievement rates of each, and of all three, quality indicators were suboptimal, indicating there are still unmet needs in the management of T2DM.

Evaluating the Long-Term Health Economic Implications of Improving the Proportion of Patients with Type 2 Diabetes Meeting Treatment Targets in Mexico

ObjectivesTo analyze the health economic implications of increasing the proportion of patients with type 2 diabetes meeting treatment targets for glycemia, blood pressure, and serum lipid levels in Mexico. MethodsComplication rates, life expectancy, quality-adjusted life expectancy, and costs were projected over patient lifetimes using a published and validated diabetes model (with outcomes discounted at 5% annually). Baseline cohort characteristics were derived from the Mexican cohort of A1chieve. Scenarios in which 20% to 80% of the patients achieved glycemic targets (glycosylated hemoglobin [HbA1c] level of 7%) only, or blood pressure and lipid targets (based on international guidelines) in addition to glycemic targets were compared with current standard of care. ResultsIncreasing the proportion of patients meeting Hb A1c targets was projected to increase mean life expectancy and quality-adjusted life expectancy by up to 0.60 years and 0.34 quality-adjusted life-years over current care. When patients achieved all treatment targets, clinical benefits were greater than when only the Hb A1c level was controlled. Increasing the proportion of patients reaching the glycemic target was projected to lead to cost savings over conventional treatment, reducing mean costs by up to Mexican pesos 42,389 (US $3314). Surprisingly, bringing patients to other targets, as well as the Hb A1c target, did not result in greater cost savings. This was as a result of the increased life expectancy in these simulations, leading to greater costs in the final years (survival paradox). ConclusionsIncreasing the proportion of patients achieving treatment targets resulted in improved clinical outcomes and cost savings from a health care payer perspective in Mexico.

Benefit‐Based Approach to Blood Pressure Control in Older Adults

Benefit‐Based Approach to Blood Pressure Control in Older Adults

Evidence-based guidelines for the management of hypertension in children with chronic kidney disease.

Hypertension is common in children with chronic kidney disease and early evidence suggests that it is a modifiable risk factor for renal and cardiovascular outcomes. Recommendations for blood pressure management in children with chronic kidney disease can be found in various clinical practice guidelines including the 4th Task Force Report, the European Society of Hypertension pediatric recommendations, and the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for the management of blood pressure in chronic kidney disease. Unfortunately, as pediatric trial evidence is limited, there are discrepancies in the recommendations that may lead to inconsistent clinical care and practice variation. This article reviews the strength of evidence behind each of the clinical practice guideline recommendations regarding blood pressure assessment, treatment targets, and first-line antihypertensive medications. The benefits and cautions of use of clinical practice guidelines are described with emphasis on the importance of reading beyond the summary statements.

Diabetes today: missed opportunities, unacceptable variations in care and ‘indescribable tragedy’

Diabetes today: missed opportunities, unacceptable variations in care and ‘indescribable tragedy’

Similarities and Differences among Recent Hypertension Guidelines

Hypertension treatment guidelines are intended to provide recom men dations to practitioners on key issues such as diag nostic criteria and blood pressure treatment targets, the optimal use of lifestyle changes as well as drug therapy, and the management of co-existing cardiovascular risk factors. Unfortu nately, despite several major clinical outcomes trials in hypertension, there is still insufficient evidence to allow firm recommendations in important areas. A major uncertainty with potentially large impli cations for stroke and cardiovascular event rates is the systolic blood pressure target in people aged 60 years or more: should it be 150 mm Hg or 140 mm Hg? This commen tary addresses this and other controversial issues and differences of opinion across the several authoritative guidelines published in the last few years.

Improving Diabetes Care in Underserved Patients through a ?Learning Your Abcs? Education And Screening Program

Pharmacists are accessible health care professionals and can provide diabetes education and counseling to underserved patients. Knowledge of hemoglobin A1C, blood pressure and cholesterol (ABC) implications and treatment targets may improve diabetes self-management. This article describes ABC education in a community pharmacy with a large uninsured and underinsured patient population.

Personal health budgets: a divisive development?

Personal health budgets: a divisive development?

Impact of Achieved Blood Pressures on Mortality Risk and End-Stage Renal Disease Among a Large, Diverse Hypertension Population

BackgroundMedical data or clinical guidelines have not adequately addressed the ideal blood pressure (BP) treatment targets for survival and renal outcome. ObjectivesThis study sought to evaluate ranges of treated BP in a large hypertension population and compare risk of mortality and end-stage renal disease (ESRD). MethodsA retrospective cohort study within the Kaiser Permanente Southern California health system was performed from January 1, 2006, to December 31, 2010. Treated hypertensive subjects ≥18 years of age were studied. Cox proportional hazards regression models were used to evaluate the risks (hazard ratios) for mortality and/or ESRD among different BP categories with and without stratification for diabetes mellitus and older age. ResultsAmong 398,419 treated hypertensive subjects (30% with diabetes mellitus), mortality occurred in 25,182 (6.3%) and ESRD in 4,957 (1.2%). Adjusted hazard ratios (95% confidence intervals [CI]) for composite mortality/ESRD in systolic BP <110, 110 to 119, 120 to 129, 140 to 149, 150 to 159, 160 to 169, and ≥170 compared with 130 to 139 mm Hg were 4.1 (95% CI: 3.8 to 1.3), 1.8 (95% CI: 1.7 to 1.9), 1.1 (95% CI: 1.1 to 1.1), 1.4 (95% CI: 1.4 to 1.5), 2.3 (95% CI: 2.2 to 2.5), 3.3 (95% CI: 3.0 to 3.6), and 4.9 (95% CI: 4.4 to 5.5) respectively. Diastolic BP 60 to 79 mm Hg were associated with the lowest risk. The nadir systolic and diastolic BP for the lowest risk was 137 and 71 mm Hg, respectively. Stratified analyses revealed that the diabetes mellitus population had a similar hazard ratio curve but a lower nadir at 131 and 69 mm Hg but age ≥70 had a higher nadir (140 and 70 mm Hg). ConclusionsBoth higher and lower treated BP compared with 130 to 139 mm Hg systolic and 60 to 79 mm Hg diastolic ranges had worsened outcomes. Our study adds to the growing uncertainty about BP treatment targets.

Socioeconomic position and cardiovascular risk factors among people with screen-detected Type 2 DM: Six-year follow-up of the ADDITION-Denmark trial

AimsTo examine whether socioeconomic position (SEP) was associated with change in cardiovascular risk factors and meeting treatment targets for cardiovascular risk factors among individuals with screen-detected Type 2 DM at six-year follow-up. MethodsThe study population was 1533 people with Type 2 DM identified from at stepwise diabetes screening programme in general practice during 2001–2006 in the ADDITION-Denmark study. The ADDITION-study was performed as a randomised trial but the two randomisation groups were analysed as one cohort in this study. Cardiovascular risk factors were measured at baseline and repeated at follow-up (mean: 5.9 [1.4] years). Information on SEP, redeemed antihypertensive and lipid-lowering treatment were obtained from Danish registers. Multivariate analyses were performed to estimate change in cardiovascular risk factors and difference in meeting treatment targets. ResultsThe change in HbA1c, cholesterol, blood pressure and BMI were virtually the same across educational level, income level, occupational status or cohabiting status. Overall, the ability to meet treatment targets for HbA1c, cholesterol and blood pressure was not modified by SEP-group. A higher proportion of people with lower educational level or lower income level in the intensive care redeemed anti-hypertensive treatment compared to people with higher educational or income levels. ConclusionScreen-detection and early treatment onset did not introduce socioeconomic inequality in metabolic control in people with screen-detected Type 2 DM at six-year follow-up.