Target Diastolic Blood Pressure Research Articles

Blood pressure targets for hypertension in patients with type 2 diabetes.

Clinical guidelines vary in determining optimal blood pressure targets in adults with diabetes mellitus. We systematically searched PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov in March 2018; conducted random effects frequentist meta-analyses of direct aggregate data; and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. From eligible 14 meta-analyses and 95 publications of randomized controlled trials (RCT), only 6 RCTs directly compared lower versus higher blood pressure targets; remaining RCTs aimed at comparative effectiveness of hypotensive drugs. In adults with diabetes mellitus and elevated systolic blood pressure (SBP), direct evidence (2 RCTs) suggests that intensive target SBP <120-140 mmHg decreases the risk of diabetes-related mortality [relative risk (RR) =0.68; 95% confidence interval (CI), 0.50-0.92], fatal (RR =0.41; 95% CI, 0.20-0.84) or nonfatal stroke (RR =0.60; 95% CI, 0.43-0.83), prevalence of left ventricular hypertrophy and electrocardiogram (ECG) abnormalities, macroalbuminuria, and non-spine bone fractures, with no differences in all-cause or cardiovascular mortality or falls. In adults with diabetes mellitus and elevated diastolic blood pressure (DBP) ≥90 mmHg, direct evidence (2 RCTs) suggests that intensive DBP target ≤80 versus 80-90 mmHg decreases the risk of major cardiovascular events. Published meta-analyses of aggregate data suggested a significant association between lower baseline and attained blood pressure and increased cardiovascular mortality. We concluded that in adults with diabetes mellitus and arterial hypertension, in order to reduce the risk of stroke, clinicians should target blood pressure at 120-130/80 mmHg, with close monitoring for all drug-related harms.

The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice.

This set of recommendations from ISSHP is designed to assist clinicians throughout the world in the recognition and management of the hypertensive disorders of pregnancy; the document includes sections written by those working in low and middle income countries so as to ensure applicability in all parts of the world. Some key points include: ISSHP does not recommend classifying pre-eclampsia as ‘mild’ or ‘severe’ because the condition may progress rapidly and unpredictably. Proteinuria is not mandatory for a diagnosis of pre-eclampsia. The HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low platelets) is one (serious) manifestation of pre-eclampsia and not a separate disorder. ISSHP supports first trimester screening for risk of pre-eclampsia when this can be integrated into the local health system, although the cost effectiveness of this approach remains to be established. ISSHP recommends that women with established strong clinical risk factors for pre-eclampsia (i.e., prior pre-eclampsia, chronic hypertension, pre-gestational diabetes, maternal BMI >30 kg/m2, antiphospholipid syndrome and receipt of assisted reproduction) be treated, ideally before 16 weeks but definitely before 20 weeks, with low dose aspirin (defined as 75–162 mg/day, as studied in RCTs). ISSHP recommends at this stage against the routine clinical use of ‘rule-in’ or ‘rule-out’ tests (specifically PlGF or sFLT-1/PlGF ratio) for pre-eclampsia. Regardless of the hypertensive disorder of pregnancy, blood pressure requires urgent treatment in a monitored setting when severe (>160/110 mmHg). For pre-eclampsia, target diastolic blood pressure is 85 mmHg in the office/clinic (and systolic blood pressure of 110–140 mmHg). Women with pre-eclampsia who have proteinuria and severe hypertension, or hypertension with neurological signs or symptoms, should receive magnesium sulphate (MgSO4) for convulsion prophylaxis. Annual medical review is advised life-long and all such women should adopt a healthy lifestyle that includes exercise, eating well and aiming for ideal body weight.

Influence of Gestational Age at Initiation of Antihypertensive Therapy: Secondary Analysis of CHIPS Trial Data (Control of Hypertension in Pregnancy Study).

URL: https://www.isrctn.com. Unique identifier: ISRCTN71416914.

Diastolic Blood Pressure and Adverse Outcomes in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) Trial.

BackgroundAlthough diastolic blood pressure (DBP) is independently associated with an increased risk of adverse cardiovascular outcomes in the general population, it is unclear if a similar relationship exists in patients with heart failure with preserved ejection fraction.Methods and ResultsThis analysis included 1703 (mean age, 72±10 years; 50% men; 78% white) patients with heart failure with preserved ejection fraction enrolled in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) Trial from the Americas who were treated for hypertension. Multivariable Cox regression was used to examine the risk of hospitalization for heart failure, death, and cardiovascular death associated with DBP. The relationship between hospitalization for heart failure and DBP was linear, with an increased risk observed with decreasing DBP values (≥90 mm Hg: referent; 80–89 mm Hg: hazard ratio [HR], 1.44; 95% confidence interval [CI], 0.85–2.44; 70–79 mm Hg: HR, 1.18; 95% CI, 0.69–2.01; 60–69 mm Hg: HR, 1.54; 95% CI, 0.90–2.63; <60 mm Hg: HR, 2.12; 95% CI, 1.20–3.74; P=0.0055 for trend). The associations of DBP with death (≥90 mm Hg: HR, 1.86; 95% CI, 1.12–3.06; 80–89 mm Hg: HR, 1.23; 95% CI, 0.89–1.70; 70–79 mm Hg: referent; 60–69 mm Hg: HR, 1.20; 95% CI, 0.90–1.59; <60 mm Hg: HR, 1.68; 95% CI, 1.21–2.33) and cardiovascular death (≥90 mm Hg: HR, 2.02; 95% CI, 1.10–3.71; 80–89 mm Hg: HR, 1.17; 95% CI, 0.77–1.79; 70–79 mm Hg: referent; 60–69 mm Hg: HR, 1.16; 95% CI, 0.80–1.70; <60 mm Hg: HR, 1.85; 95% CI, 1.21–2.82) were nonlinear, with a greater risk of each outcome observed with DBP values ≥90 and <60 mm Hg.Conclusions DBP values ≥90 and <60 mm Hg are associated with a significant risk of adverse outcomes in patients with heart failure with preserved ejection fraction who are treated for hypertension. Further research is needed to determine optimal DBP targets to reduce the risk of adverse events in patients with heart failure with preserved ejection fraction.

Prevention of stroke: Antihypertensives, cholesterol-lowering drugs, antithrombotics, anticoagulation, carotid surgery, and stenting

Antihypertensive drugs are very effective in secondary stroke prevention. More important than the choice of a class of antihypertensives is to achieve the systolic and diastolic blood pressure targets (

Blood pressure target in 2017

The issue of how far blood pressure (BP) should be lowered under antihypertensive treatment is still an important matter of scientific debate. The aim of the present review is to consider the clinical relevance of individualized BP goal under treatment in hypertensive patients according to their age, comorbidities or established cardio-vascular (CV) disease. The French and European recommendations propose a systolic BP target between 130 and 139mmHg (<150mmHg after 80 years) and diastolic BP target <90mmHg in hypertensive patients whatever their level of risk. The results of the recent SPRINT study suggest that a more ambitious systolic BP target, <120mmHg, significantly reduces CV morbidity and mortality, but with an increased iatrogenic risk. Several questions in everyday practice have to be considered. An important issue concerns BP measurement methods in this clinical trial (Dinamap) versus in routine clinical practice and the implications on BP treatment targets. In addition, close monitoring of participants in clinical trials and active orthostatic hypotension research limit the incidence of adverse events related to intensive treatement. Finally, in the presence of an established CV disease, an intensive therapeutic approach could be associated with a J-curve relationship between BP level and CV events. An early and strict BP control in young or middle-aged hypertensive patients in primary prevention should be a priority. In this hypertensive population with low to moderate CV risk, without established CV or renal diseases, more stringent than recommended BP-lowering treatment could potentially prevent hypertensive arterial damage and thus correct the increased residual CV risk later in life. The tolerance of an intensive therapeutic approach should remain a concern in elderly patients and in patients with established CV disease.

P3562A new approach to diastolic blood pressure targets in patients with hypertension and coronary artery disease

P3562A new approach to diastolic blood pressure targets in patients with hypertension and coronary artery disease

Do Labetalol and Methyldopa Have Different Effects on Pregnancy Outcome? Analysis of Data From the Control of Hypertension In Pregnancy Study (CHIPS) Trial

(BJOG. 2016;123:1143–1151) The Control of Hypertension In Pregnancy Study (CHIPS trial) investigated the impact of a target blood pressure (BP) on maternal and perinatal outcomes by randomizing women with gestational or preexisting hypertension to a diastolic BP target of 100 (“less tight” control group) versus 85 mm Hg (“tight” control group). The present study, a secondary analysis of the CHIPS trial data, aimed to compare pregnancy outcomes between women taking methyldopa or labetalol while considering the allocation of these patients to the “less tight” or “tight” control group.

EFFICIENCY EVALUATION OF A NOVEL CLINICAL AND ORGANIZATIONAL APPROACH TO THE SECONDARY PREVENTION OF ARTERIAL HYPERTENSION IN PRIMARY HEALTH CARE SETTINGS

The purpose . We aimed to develop, implement and evaluate the efficiency of a novel clinical and organization approach to the medical prevention of cardiovascular diseases in primary health care settings. Material and methods. The comparative assessment of the results of dispensary observation of patients with AH was conducted in the main group (n=308) who underwent a novel prevention program and in the control group (n=240) who were under the usual supervision of a general practitioner. The mean age of the patients in the groups was 59.0±10.8 and 57.5±10.47 years respectively. The basis of the novel prevention technology is the assessment of cardiovascular risk and the development of patients’ itinerary at the pre-hospital stage using the medical information system. Results. In the group with AH who underwent a novel prevention program, a number of patients who had achieved the target systolic and diastolic blood pressure and target cholesterol level was significantly higher than in the control group. The patients of the main group visited a hospital for AH decompensation significantly less frequent. The patients in the main group were more compliant with diagnostic tests and consultations of the specialists as compared to the patients in the control group. The patients of the main group more often attended the classes of the School of Health included into the prevention program. The duration of the observation period was 12±6.5 months. Conclusion . The study proved that the individual prevention program at the pre-hospital stage reduced the prevalence and the severity degree of cardiovascular risk factors and increased the number of patients who had reached the target values of the controlled risk factors after 12±6.5 months of observation. It is achieved by the compliance with requirements of the Russian guidelines and the higher adherence of patients to the preventive measures.

Should Patients With Cardiovascular Risk Factors Receive Intensive Treatment of Hypertension to

Opposing Viewpoint, see p 1308 Epidemiologic studies show a graded increase in risk at systolic blood pressure (BP) >115 mm Hg and diastolic BP >75 mm Hg. However, it remains unclear whether pharmacologic BP lowering to these levels reduces cardiovascular (CV) events and is safe. Observational analyses raised concerns about aggressive BP lowering to levels <120/80 mm Hg, suggesting the existence of a J-curve phenomenon with increased risk especially for coronary events. However, such analyses are potentially confounded. More reliable data are provided by randomized trials. Most BP-lowering trials have evaluated patients with high pretreatment BP and have rarely achieved average systolic BP <130 to 140 mm Hg, except in patients with high-risk CV disease, such as recent myocardial infarction (MI) or heart failure (HF) or those with chronic kidney disease. Three recent trials have specifically compared intensive systolic BP lowering to targets of <120 to 130 mm Hg versus traditional guideline recommended targets of generally <140 mm Hg,1–3 while the older HOT trial (Hypertension Optimal Treatment) randomized patients to diastolic BP targets of ≤90, ≤85, or ≤80 mm Hg.4 These trials differ significantly in their design, patients’ characteristics and CV risk, BP regimens, duration of treatment, primary outcomes, BP measurement techniques, and results. The ACCORD trial (Action to Control Cardiovascular Risk in Diabetes) randomized 4733 patients with diabetes (mean 63 years of age, 34% with a previous CV event, BP 139/76 mm Hg) to intensive therapy to a systolic BP target <120 mm Hg or to a standard target <140 mm Hg.1 Intensive therapy lowered BP by …

Women's views and postpartum follow-up in the CHIPS Trial (Control of Hypertension in Pregnancy Study)

ObjectiveTo compare women's views about blood pressure (BP) control in CHIPS (Control of Hypertension In Pregnancy Study) (NCT01192412). DesignQuantitative and qualitative analysis of questionnaire responses. SettingInternational randomised trial (94 sites, 15 countries). Population/sample911 (92.9%) women randomised to ‘tight’ (target diastolic blood pressure, 85mmHg) or ‘less tight’ (target diastolic blood pressure, 100mmHg) who completed questionnaires. MethodsA questionnaire was administered at ∼6–12 weeks postpartum regarding post-discharge morbidity and views about trial participation. Questionnaires were administered by the site co-ordinator, and contact was made by phone, home or clinic visit; rarely, data was collected from medical records. Quantitative analyses were Chi-square or Fisher's exact test for categorical variables, mixed effects multinomial logistic regression to adjust for confounders, and p<0.001 for statistical significance. NVivo software was used for thematic analysis of women's views. Main outcome measuresSatisfaction, measured as willingness to have the same treatment in another pregnancy or recommend that treatment to a friend. ResultsAmong the 533 women in ‘tight’ (N=265) vs. ‘less tight’ (N=268) control who provided comments for qualitative analysis, women in ‘tight’ (vs. ‘less tight’) control made fewer positive comments about the amount of medication taken (5 vs. 28 women, respectively) and intensity of BP monitoring (7 vs. 17, respectively). However, this did not translate into less willingness to either have the same treatment in another pregnancy (434, 95.8% vs. 423, 92.4%, respectively; p=0.14) or recommend that treatment to a friend (435, 96.0% and 428, 93.4%, respectively; p=0.17). Importantly, although satisfaction remained high among women with an adverse outcome, those in ‘tight’ control who suffered an adverse outcome (vs. those who did not) were not consistently less satisfied, whereas this was not the case among women in ‘less tight’ control among whom satisfaction was consistently lower for the CHIPS primary outcome (p<0.001), severe hypertension (p≤0.01), and pre-eclampsia (p<0.001). ConclusionsWomen in ‘tight’ (vs. ‘less tight’) control were equally satisfied with their care, and more so in the face of adverse perinatal or maternal outcomes.

The Impact of Left Ventricular Mass on Diastolic Blood Pressure Targets for Patients With Coronary Artery Disease.

Defining the optimal diastolic blood pressure (DBP) for patients with hypertension and coronary artery disease (CAD) is an ongoing challenge in part because of the concern that low DBP may have adverse cardiac effects (the J curve hypothesis). Left ventricular mass (LV mass) was measured on the echocardiogram of individuals (N = 92) with CAD who had coronary blood flow (CBF) in the left anterior descending (LAD) artery estimated from artery diameter and DBP distal to coronary stenosis. CBF approached 0 in a small but defined proportion of persons at DBP of 70mm Hg. CBF was significantly lower in persons with higher LV mass (above the median of 83g/m(2)) when DBP was ≥75mm Hg. Higher electrocardiogram QRS voltage (sum of S V1 and R in V6), in the absence of LV hypertrophy (LVH), identified persons with significantly lower CBF at DBP ≥ 80mm Hg. In multivariate analysis, LV mass was a significant CBF determinant after adjusting for DBP and CAD severity. LV mass has a major impact on CBF when DBP is >70mm Hg, while DBP is the primary determinant of CBF when DBP is ≤70mm Hg. Multivariate analysis confirmed a significant interaction between LV mass and DBP. DBP ≤ 70mm Hg is associated with a progressively greater proportion in whom CBF in the LAD approaches 0. For DBP > 70mm Hg, persons with higher LV mass, even in the absence of LVH, have lower CBF, suggesting LV mass is an important consideration when DBP is reduced in patients with CAD.

Recommendations for Intensive Blood Pressure Lowering in High-Risk Patients, the Canadian Viewpoint.

Recent publication of the Systolic Blood Pressure Intervention Trial (SPRINT) in close temporal proximity to 2 meta-analyses affirming the benefits of intensive blood pressure (BP) control collectively signify the need to reevaluate BP targets in hypertensive patients at high risk for cardiovascular events.1–3 This commentary discusses how this recent evidence has affected Canadian clinical practice guidelines, describes the process used to update these guidelines in light of this evidence, and outlines the major issues deliberated by Canadian Hypertension Education Program (CHEP) Task Force members during this process. In the SPRINT trial, which studied 9361 subjects aged ≥50 years at increased risk for cardiovascular events, intensive systolic BP control (to <120 mm Hg) reduced the incidence of cardiovascular events and mortality by 25% (5.2% versus 6.8%; hazard ratio 0.75; 95% confidence interval 0.64–0.89) compared with standard systolic BP control (135–139 mm Hg).1 Furthermore, a meta-analysis of 55 randomized controlled trials (265 576 subjects) demonstrated that the reduction in cardiovascular events realized from a 10-mm Hg systolic BP reduction is similar across different quintiles of baseline systolic BP (<130, 130–139, 140–149, 150–159, ≥160 mm Hg).2 In a second meta-analysis of 14 treat-to-target trials (44 989 subjects), a 7-mm Hg mean systolic BP reduction (from 140 to 133 mm Hg) led to a 14% (95% confidence interval 0.78–0.96) reduction in major cardiovascular events.3 In aggregate, these data support the implementation of intensive BP control in high-risk patients. Canadian hypertension clinical practice guidelines are crafted and disseminated by the multidisciplinary 75-member CHEP Recommendations Task Force, a process that is funded by Hypertension Canada.4 CHEP has produced annually updated recommendations for the diagnosis and management of high BP since 1999.5 The CHEP process consists of the following: 1. A Cochrane librarian conducts literature searches in collaboration with Task Force members. These searches are designed to inform …

Blood pressure and antihypertensive medication profile in a multiethnic Asian population of stable chronic kidney disease patients.

Clinical practice guidelines recommend different blood pressure (BP) goals for chronic kidney disease (CKD) patients. Usage of antihypertensive medication and attainment of BP targets in Asian CKD patients remain unclear. This study describes the profile of antihypertensive agents used and BP components in a multiethnic Asian population with stable CKD. Stable CKD outpatients with variability of serum creatinine levels < 20%, taken > 3 months apart, were recruited. Mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using automated manometers, according to practice guidelines. Serum creatinine was assayed and the estimated glomerular filtration rate (GFR) calculated using the CKD Epidemiology Collaboration equation. BP and antihypertensive medication profile was examined using univariate analyses. 613 patients (55.1% male; 74.7% Chinese, 6.4% Indian, 11.4% Malay; 35.7% diabetes mellitus) with a mean age of 57.8 ± 14.5 years were recruited. Mean SBP was 139 ± 20 mmHg, DBP was 74 ± 11 mmHg, serum creatinine was 166 ± 115 µmol/L and GFR was 53 ± 32 mL/min/1.73 m(2). At a lower GFR, SBP increased (p < 0.001), whereas DBP decreased (p = 0.0052). Mean SBP increased in tandem with the number of antihypertensive agents used (p < 0.001), while mean DBP decreased when ≥ 3 antihypertensive agents were used (p = 0.0020). Different targets are recommended for each BP component in CKD patients. A majority of patients cannot attain SBP targets and/or exceed DBP targets. Research into monitoring and treatment methods is required to better define BP targets in CKD patients.

Gender difference in the response to valsartan/amlodipine single-pill combination in essential hypertension (China Status II): An observational study.

Background:The China STATUS II is a prospective, multicentre, open-label, post-marketing, observational study including Chinese adults (aged ⩾ 18 years) with essential hypertension who were prescribed once-daily valsartan/amlodipine (Val/Aml 80/5 mg) single-pill combination. In order to examine gender differences in treatment response to Val/Aml, we further analysed data from the China STATUS II study.Methods:A total of 11,312 patients (6456 (57%) men and 4856 (43%) women) received the Val/Aml treatment for 8 weeks. After the treatment, we compared the proportion of patients not achieving the target systolic blood pressure (SBP: < 140 mm Hg) or diastolic blood pressure (DBP: < 90 mm Hg) in different age groups (by Fisher exact probability test) and estimated the changes in blood pressure (BP) according to age and gender, using a mixed model.Results:At enrolment, mean SBP was higher in the female versus the male patients (160.0 ± 12.71 versus 159.3 ± 12.31 mm Hg; p = 0.003), whereas the mean DBP was higher in the male versus the female patients (96.4 ± 10.65 versus 94.5 ± 10.72 mm Hg; p < 0.001). The overall proportion of women not achieving the target BP was less than that of men (57.41% versus 59.59%; p < 0.05) at 4 weeks and (22.22% versus 23.78%; p < 0.05) at 8 weeks after the Val/Aml treatment. Among both men and women, the proportion of patients not achieving the target SBP increased with age; however, the proportion not achieving the target DBP decreased with age. The mixed-model analysis showed that the changes in SBP were closely related to gender, indicating that the SBP-lowering effect after Val/Aml treatment might be better in women. In addition, the changes in DBP were closely related to age.Conclusions:Gender might be a factor for consideration in the decision-making process of individualised antihypertensive therapy, in the future.

PP.07.26

Objective: To compare the response to once-daily valsartan/amlodipine (Val/Aml, 80/5 mg) single-pill combination therapy according to sex in CHINA STATUS II. Design and method: 1,1312 patients (6456 (57%) men and 4856 (43%) women) were analyzed. Patients were treated for 8 weeks. The percentages of not achieving the target systolic blood pressure (SBP > = 140 mm Hg) or diastolic blood pressure (DBP > = 90 mm Hg) were compared in different age groups of men and women, respectively at the baseline, 4 weeks and 8 weeks after Val/Aml treatment. The mixed model hierarchically estimated changes of BP according to different age and gender at 4 weeks and 8 weeks after therapy. Results: At enrollment, SBP was lower in men (159.30 ± 12.31 mm Hg) than in women (160.00 ± 12.71 mm Hg, P = 0.003), whereas DBP was higher in men (96.40 ± 10.65 mm Hg) than in women (94.50 ± 10.72 mm Hg, P < 0.001). Whether male or female, the percentage of not achieving target SBP was increased with age; however, the percentage of not achieving target DBP was decreased with age. The percentage of not achieving target BP in female were less than those in male (57.41% vs. 59.59%, P < 0.05 at 4 weeks and 22.22% vs. 23.78%, P < 0.05, OR = 0.95, 95% CI = 0.90, 0.99 at 8 weeks after Val/Aml treatment). Compared with male after Val/Aml treatment, the decrease values of SBP were more in female (20.07 ± 11.97 vs. 19.62 ± 11.07 mm Hg, P < 0.0001 at 4 weeks and 27.68 ± 12.56 vs. 26.74 ± 11.93 mm Hg, P = 0.0003 at 8 weeks), while the decrease values of DBP in female were less (P = 0.0009 and P < 0.0001). The mixed model analysis showed that the difference in SBP was closely related with sex, that lower SBP effect in female was better than it in male after Val/Aml treatment. The difference in DBP was closely related with age. Conclusions: Gender might be a factor to be taken in the individualized antihypertensive therapy.

A review of the JNC 8 Blood Pressure Guideline.

Hypertension is a major independent risk factor for coronary artery disease, stroke, heart failure, and renal failure. One of every 3 American adults—or approximately 67 million adults (31%)—has hypertension (HTN).1 A person over the age of 55 years has a 90% lifetime risk of developing HTN.2 Hypertension accounts for 18% of cardiovascular disease deaths in Western countries.3 High blood pressure (BP) costs the nation $47.5 billion each year.4 In 2014, the Eighth Joint National Committee (JNC 8) published the evidence-based guideline for the management of high BP in adults. This new guideline was characterized by a systematic review of the literature with an emphasis on randomized, controlled clinical trials. The guideline attempted to answer 3 key questions.5 In adults with HTN, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? In adults with HTN, do attempts to reach specified BP goals with antihypertensive pharmacologic therapy lead to improvements in health outcomes? In adults with HTN, do various antihypertensive drugs or drug classes differ in regard to specific health outcomes?5 The committee provided 9 graded recommendations to answer the 3 key questions. Grading was performed on the basis of the strength of the available evidence used to make the recommendation: grade A is indicative of strong evidence, grade B of moderate evidence, grade C of weak evidence, and grade E of expert opinion (in lieu of sufficient evidence). Below are the 9 recommendations.5 Recommendation 1. The guideline recommends the initiation of drug therapy in order to lower a systolic BP (SBP) of ≥150 mmHg or a diastolic BP (DBP) of ≥90 mmHg for the general population at 60 years of age or older (Grade A). A corollary recommendation is that patients whose achieved SBP on pharmacologic therapy is lower than the new guideline recommendation can be continued at that level of therapy, if well tolerated (Grade E). Recommendation 2. The target DBP to start pharmacologic therapy for subjects younger than 60 years of age is ≥90 mmHg. On the basis of available evidence, the recommendation for patients aged 30 to 59 years is strong (Grade A). For those between the ages of 18 and 29, the recommendation is on the basis of expert opinion (Grade E). Recommendation 3. The target SBP to start pharmacologic therapy for subjects younger than 60 years of age is ≥140 mmHg (Grade E). Recommendation 4. In the population aged 18 years or older with chronic kidney disease, initiate pharmacologic treatment to lower BP at SBP ≥140 mmHg or DBP ≥90 mmHg and treat to a goal of SBP <140mmHg and a goal of DBP <90 mmHg (Grade E). Recommendation 5. The target blood pressure in beginning pharmacologic therapy for the diabetic population aged 18 years or older is <140 mmHg for SBP and <90 mmHg DBP (Grade E). Recommendation 6. Initial drug therapy for nonblack patients (including diabetic patients) should include a thiazide-type diuretic, a calcium channel blocker, an angiotensin-converting enzyme (ACE) inhibitor, or an angiotensin receptor blocker (Grade B). Recommendation 7. Initial drug therapy for black patients should include a thiazide-type diuretic or a calcium channel blocker. This includes patients with diabetes mellitus (Grade B; for diabetic black patients, Grade C). Recommendation 8. For patients 18 years and older with chronic kidney disease, initial or additional therapy should include an ACE inhibitor or angiotensin receptor blocker, regardless of race or diabetic status (Grade B). Recommendation 9. An algorithm for managing patients who do not achieve control within one month is recommended. If the goal is not achieved, increase the dose of the initial drug or add a 2nd drug from one of the classes in recommendation 6. A 3rd drug should be added if the goal is not achieved with 2 drugs. Drugs from other classes can be used if the target is not achieved with the recommended classes, or if there is a contraindication to one of the recommended drug classes. ACE inhibitors should not be combined with angiotensin receptor blockers in the same patient. Referral to an HTN specialist should be considered in complicated cases or in the event of inability to control BP (Grade E).5

Randomized controlled trials of blood pressure lowering in hypertension: a critical reappraisal.

Sixty-eight blood pressure (BP)-lowering randomized controlled trials (defined as randomized controlled trials comparing active treatment with placebo, or less active treatment, achieving a BP difference, performed between 1966 and end 2013 in cohorts with ≥ 40% hypertensive patients, and exclusive of trials in acute myocardial infarction, heart failure, acute stroke, and dialysis) were identified and meta-analyzed grouping the randomized controlled trials on the basis of clinically relevant questions: (1) does BP lowering reduce all types of cardiovascular outcome? (2) Is prevention of all outcomes proportional to the extent of systolic, diastolic, and pulse BP? (3) Have all classes of BP-lowering drugs been shown capable of reducing all types of cardiovascular outcome? (4) Is BP lowering beneficial when intervention is initiated at any grade (or stage) of hypertension? (5) Do BP-lowering randomized controlled trials provide evidence about systolic BP and diastolic BP targets of treatment? (6) Should BP-lowering treatment be preferentially addressed to patients in higher risk categories promising larger absolute treatment benefits? The results of these meta-analyses provide further support to current hypertension treatment guidelines by showing that BP lowering can significantly reduce major cardiovascular outcomes largely independent of the agents used, significant risk reduction is found at all hypertension grades (stages), and when systolic BP is lowered below a cut off of 140 mm Hg with some further reduction limited to stroke at systolic BP values just <130 mm Hg. Absolute risk reduction progressively increases higher is total cardiovascular risk, but this greater benefit is associated with a progressively higher residual risk, ie, higher treatment failures.

Less-Tight versus Tight Control of Hypertension in Pregnancy

BackgroundThe effects of less-tight versus tight control of hypertension on pregnancy complications are unclear.MethodsWe performed an open, international, multicenter trial involving women at 14 weeks 0 days to 33 weeks 6 days of gestation who had nonproteinuric preexisting or gestational hypertension, office diastolic blood pressure of 90 to 105 mm Hg (or 85 to 105 mm Hg if the woman was taking antihypertensive medications), and a live fetus. Women were randomly assigned to less-tight control (target diastolic blood pressure, 100 mm Hg) or tight control (target diastolic blood pressure, 85 mm Hg). The composite primary outcome was pregnancy loss or high-level neonatal care for more than 48 hours during the first 28 postnatal days. The secondary outcome was serious maternal complications occurring up to 6 weeks post partum or until hospital discharge, whichever was later.ResultsIncluded in the analysis were 987 women; 74.6% had preexisting hypertension. The primary-outcome rates were similar among 493 women assigned to less-tight control and 488 women assigned to tight control (31.4% and 30.7%, respectively; adjusted odds ratio, 1.02; 95% confidence interval [CI], 0.77 to 1.35), as were the rates of serious maternal complications (3.7% and 2.0%, respectively; adjusted odds ratio, 1.74; 95% CI, 0.79 to 3.84), despite a mean diastolic blood pressure that was higher in the less-tight-control group by 4.6 mm Hg (95% CI, 3.7 to 5.4). Severe hypertension (≥160/110 mm Hg) developed in 40.6% of the women in the less-tight-control group and 27.5% of the women in the tight-control group (P<0.001).ConclusionsWe found no significant between-group differences in the risk of pregnancy loss, high-level neonatal care, or overall maternal complications, although less-tight control was associated with a significantly higher frequency of severe maternal hypertension. (Funded by the Canadian Institutes of Health Research; CHIPS Current Controlled Trials number, ISRCTN71416914; ClinicalTrials.gov number, NCT01192412.)

Self-reported medication adherence and blood pressure control rates in patients with chronic kidney disease

Background: Self-reporting though thought to be unreliable, is often used to assess medication adherence in clinical practice. The aim of this study was to determine self-reported medication adherence and blood pressure control rates in patients with chronic kidney disease (CKD). Patients and Methods: This was a cross-sectional survey of patients with CKD attending a nephrology out-patient clinic in Lagos. Recruited patients had been attending the clinic for >1 year and had >4 clinic visits. CKD was defined as glomerular filtration rate 2 , medication adherence was assessed according to the simplified medication adherence questionnaire, while target blood pressure was defined as a sitting recording Results: A total of 91 patients (50.5% female) were studied. The mean age (years) of the study population was 49.5 ΁ 13 (range 22-78). The mean glomerular filtration rate (ml/min/1.73 m 2 ) was 23.5 ΁ 16.0 (range 4-59). Overall, 61 (67%) patients were adherent while 23 (25.3%) had their blood pressures controlled to target. Control rates were similar regardless of adherence status ( P = 0.19). Adherent patients had significantly lower mean systolic blood pressures ( P P = 0.02). Conclusion: Medication adherence rates and blood pressure control rates reported here are similar to previous studies. Adherent patients were more likely to achieve systolic blood pressure targets <130 mmHg, but not diastolic blood pressure targets of <80 mmHg.