Lower Blood Pressure Targets Research Articles

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 …

Malignant hypertension: new aspects of an old clinical entity

Malignant hypertension (MHT), also known as accelerated-malignant hypertension or malignant-phase hypertension, is the most severe form of arterial hypertension. It is defined clinically as high blood pressure (BP) levels associated with lesions of the retinal fundus (flame-shaped hemorrhages, exudates, or cotton wool spots, with or without papilledema). Despite the availability of a vast range of antihypertensive agents, MHT continues to be a significant clinical challenge. Although its prevalence is very low, the absolute number of new cases has not changed over the past decades. While the role of the activation of the renin-angiotensin-aldosterone system and endothelial dysfunction in the pathogenesis of MHT has been well described, recent studies have indicated that the immune system may also play an important role in the development of this condition. Patients with MHT are characterized by pronounced target organ damage, including structural and functional cardiac abnormalities. MHT is frequently complicated by renal insufficiency and end-stage renal disease. The survival rates for patients with MHT have improved considerably with increased availability of antihypertensive treatment. However, renal insufficiency and end-stage renal disease still remain a significant cause of morbidity and mortality in this patient group. In conclusion, MHT is not a "vanishing disease" because there is a relatively stable number of new cases per year. Nonetheless, prognosis and survival rates in these patients have improved significantly owing to earlier detection, stricter BP control, lower BP targets, better choice of antihypertensive drugs, and availability of hemodialysis and renal transplantation.

NIH study results support lower blood pressure target with drugs

NIH study results support lower blood pressure target with drugs

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

Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis

Recent hypertension guidelines have reversed previous recommendations for lower blood pressure targets in high-risk patients, such as those with cardiovascular disease, renal disease, or diabetes. This change represents uncertainty about whether more intensive blood pressure-lowering strategies are associated with greater reductions in risk of major cardiovascular and renal events. We aimed to assess the efficacy and safety of intensive blood pressure-lowering strategies. For this updated systematic review and meta-analysis, we systematically searched MEDLINE, Embase, and the Cochrane Library for trials published between Jan 1, 1950, and Nov 3, 2015. We included randomised controlled trials with at least 6 months' follow-up that randomly assigned participants to more intensive versus less intensive blood pressure-lowering treatment, with different blood pressure targets or different blood pressure changes from baseline. We did not use any age or language restrictions. We did a meta-analysis of blood pressure reductions on relative risk (RR) of major cardiovascular events (myocardial infarction, stroke, heart failure, or cardiovascular death, separately and combined), and non-vascular and all-cause mortality, end-stage kidney disease, and adverse events, as well as albuminuria and progression of retinopathy in trials done in patients with diabetes. We identified 19 trials including 44,989 participants, in whom 2496 major cardiovascular events were recorded during a mean 3·8 years of follow-up (range 1·0-8·4 years). Our meta-analysis showed that after randomisation, patients in the more intensive blood pressure-lowering treatment group had mean blood pressure levels of 133/76 mm Hg, compared with 140/81 mm Hg in the less intensive treatment group. Intensive blood pressure-lowering treatment achieved RR reductions for major cardiovascular events (14% [95% CI 4-22]), myocardial infarction (13% [0-24]), stroke (22% [10-32]), albuminuria (10% [3-16]), and retinopathy progression (19% [0-34]). However, more intensive treatment had no clear effects on heart failure (15% [95% CI -11 to 34]), cardiovascular death (9% [-11 to 26]), total mortality (9% [-3 to 19]), or end-stage kidney disease (10% [-6 to 23]). The reduction in major cardiovascular events was consistent across patient groups, and additional blood pressure lowering had a clear benefit even in patients with systolic blood pressure lower than 140 mm Hg. The absolute benefits were greatest in trials in which all enrolled patients had vascular disease, renal disease, or diabetes. Serious adverse events associated with blood pressure lowering were only reported by six trials and had an event rate of 1·2% per year in intensive blood pressure-lowering group participants, compared with 0·9% in the less intensive treatment group (RR 1·35 [95% CI 0·93-1·97]). Severe hypotension was more frequent in the more intensive treatment regimen (RR 2·68 [1·21-5·89], p=0·015), but the absolute excess was small (0·3% vs 0·1% per person-year for the duration of follow-up). Intensive 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. National Health and Medical Research Council of Australia.

NIH: Lives Saved With Lower Systolic Blood Pressure

Deaths were reduced by nearly one-quarter when systolic blood pressure was treated to a target of 120 rather than 140 mm Hg, according to a large National Institutes of Health–sponsored study comparing standard blood pressure treatment with more-intensive lowering of systolic blood pressure. The lower blood pressure group also saw a 30% reduction in the primary composite endpoint of cardiovascular events, stroke, and cardiovascular death. The magnitude of the effect of the lower blood pressure target prompted the study's data safety monitoring board to end the study early, said officials from several NIH agencies at a telebriefing. The study was unblinded in August, and a full report of the primary outcome measures will come in a paper due out by the end of the year, they said. The Systolic Blood Pressure Inter-vention Trial, or SPRINT, is a 100-site trial that enrolled more than 9,300 people in the United States and Puerto Rico at least 50 years old who had high blood pressure and who were at risk for cardiovascular disease; those with diabetes were excluded. Patients were randomized to a standard treatment target of 140 mm Hg or less or to a more intensive 120 mm Hg. SPRINT participants received evidence-based treatment with a variety of antihypertensives, with the intervention arm requiring an average of almost three medications, compared with just under two for the less-intensive treatment arm. Against a backdrop of uncertainty in the literature about what the target systolic blood pressure should be for those with hypertension and at risk for cardiovascular events or kidney disease, the study provides compelling evidence that more aggressive blood pressure lowering is important. “More-intensive management of blood pressure can save lives,” said Gary Gibbons, MD, director of the National Heart, Lung, and Blood Institute (NHLBI). Jackson T. Wright Jr., MD, PhD, SPRINT study lead and director of the clinical hypertension program at Case Western Reserve University in Cleveland, also emphasized that intensive blood pressure management can prevent the cardiovascular complications of hypertension. Although subgroup analysis is ongoing, the effect seems robust and consistent across age groups, sex, and ethnicity, he said. SPRINT, he said, also “offers an excellent opportunity to examine the tolerability and safety of the lower target.” The first look at the safety data shows that the more-intensive treatment is well tolerated, although data analysis is ongoing, he said. “Our results provide important evidence that treating blood pressure to a lower goal in older or high-risk patients can be beneficial and yield better health results overall,” Lawrence Fine, MD, chief, Clinical Applications and Prevention Branch at NHLBI, stated in a press release. The previous absence of compelling data played a part in the debate surrounding blood pressure levels that should be used in guidance documents, and Dr. Gibbons and Dr. Wright both emphasized that they would expect the forthcoming primary outcomes paper to have an impact on guideline-writing bodies in the future. Dr. Wright said, however, “We are not providing guidance for providers or patients right now.” In 2014, the group of experts who had constituted the Joint National Commission 8 panel, a team assembled in 2008 by the NHLBI to update official U.S. hypertension management guidelines, set the target blood pressure for the general population 60 years or older to less than 150/90 mm Hg, a major break from long-standing practice to treat such patients to a target systolic pressure of less than 140 mm Hg (JAMA 2014;311:507–20). These guidelines, released after SPRINT began, remain controversial. The SPRINT study is also examining kidney disease, cognitive function, and dementia among the patients; however, those results are still under analysis and will become available as more information is collected over the next year. Kari Oakes is with the Midwest bureau of Frontline Medical News.

Body & brain: Lower blood pressure target proposed: But full data needed to assess clinical trial's findings, experts say

Body & brain: Lower blood pressure target proposed: But full data needed to assess clinical trial's findings, experts say

Update on blood pressure control and renal outcomes in diabetes mellitus.

Diabetic nephropathy (DN) is associated with a high incidence of cardiovascular (CV) morbidity and mortality. Although relationships between hypertension and diabetic nephropathy are complex, blood pressure (BP) control is an important management strategy in the prevention of onset and progression of DN in patients with diabetes mellitus (DM). Recent guidelines recommend less stringent BP targets among patients with type 2 DM and chronic kidney disease. These recommendations are based mostly on lack of benefit in CV outcomes with a low BP target. We review the current information on efficacy of BP control in improving renal outcomes in patients with type 2 DM. Presently, although intensive BP control has been was beneficial in decreasing albuminuria, it has not translated into reductions in risks of hard renal endpoints, such as progression to end-stage renal disease, the need for renal replacement therapy, and mortality from renal causes.

Lowering blood pressure targets cuts cardiovascular disease deaths

Lowering blood pressure targets cuts cardiovascular disease deaths

Blood Pressure in Early Autosomal Dominant Polycystic Kidney Disease

BackgroundHypertension is common in autosomal dominant polycystic kidney disease (ADPKD) and is associated with increased total kidney volume, activation of the renin–angiotensin–aldosterone system, and progression of kidney disease.MethodsIn this double-blind, placebo-controlled trial, we randomly assigned 558 hypertensive participants with ADPKD (15 to 49 years of age, with an estimated glomerular filtration rate [GFR] >60 ml per minute per 1.73 m2 of body-surface area) to either a standard blood-pressure target (120/70 to 130/80 mm Hg) or a low blood-pressure target (95/60 to 110/75 mm Hg) and to either an angiotensin-converting–enzyme inhibitor (lisinopril) plus an angiotensin-receptor blocker (telmisartan) or lisinopril plus placebo. The primary outcome was the annual percentage change in the total kidney volume.ResultsThe annual percentage increase in total kidney volume was significantly lower in the low-blood-pressure group than in the standard-blood-pressure group (5.6% vs. 6.6%, P=0.006), without significant differences between the lisinopril–telmisartan group and the lisinopril–placebo group. The rate of change in estimated GFR was similar in the two medication groups, with a negative slope difference in the short term in the low-blood-pressure group as compared with the standard-blood-pressure group (P<0.001) and a marginally positive slope difference in the long term (P=0.05). The left-ventricular-mass index decreased more in the low-blood-pressure group than in the standard-blood-pressure group (−1.17 vs. −0.57 g per square meter per year, P<0.001); urinary albumin excretion was reduced by 3.77% with the low-pressure target and increased by 2.43% with the standard target (P<0.001). Dizziness and light-headedness were more common in the low-blood-pressure group than in the standard-blood-pressure group (80.7% vs. 69.4%, P=0.002).ConclusionsIn early ADPKD, the combination of lisinopril and telmisartan did not significantly alter the rate of increase in total kidney volume. As compared with standard blood-pressure control, rigorous blood-pressure control was associated with a slower increase in total kidney volume, no overall change in the estimated GFR, a greater decline in the left-ventricular-mass index, and greater reduction in urinary albumin excretion. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; HALT-PKD [Study A] ClinicalTrials.gov number, NCT00283686.)

High versus Low Blood-Pressure Target in Patients with Septic Shock: Asfar P, Meziani F, Hamel JF, et al. N Engl J Med 1014;370:1583–93.

High versus Low Blood-Pressure Target in Patients with Septic Shock: Asfar P, Meziani F, Hamel JF, et al. N Engl J Med 1014;370:1583–93.

High versus low blood-pressure target in septic shock.

To the Editor: As noted by Asfar et al. (April 24 issue),1 a major concern related to targeting a relatively low mean arterial blood pressure in patients with septic shock is that the brain is at risk for ischemia in this condition. The risk of potential brain ischemia is particularly pertinent among patients with a history of arterial hypertension, because their cerebral autoregulatory curve may be shifted to the right.2 Indeed, cerebral ischemia may contribute to sepsis-associated encephalopathy and persistent neurocognitive dysfunction.3 However, neither the primary nor the secondary outcomes in the study by Asfar et al. involved any measures of neurocognitive function. A mean arterial blood pressure of approximately 65 to 90 mm Hg describes the lower limit of autoregulation in healthy persons,4 and the same level appears to be present in critically ill patients with sepsis who do not have a history of hypertension.5 Before the findings by Asfar et al. are implemented in major guidelines, we think that further studies should address the way in which cerebral hemodynamics are specifically affected in patients with sepsis and a history of hypertension, as well as whether targeting a relatively high mean arterial blood pressure improves long-term neurocognitive function.

In septic shock, MAP targets of 80 to 85 mm Hg vs 65 to 70 mm Hg did not differ for 28-day mortality

ACP Journal Club15 July 2014In septic shock, MAP targets of 80 to 85 mm Hg vs 65 to 70 mm Hg did not differ for 28-day mortalityB. Taylor Thompson, MDB. Taylor Thompson, MDMassachusetts General Hospital, Boston, Massachusetts, USA (B.T.T.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-161-2-201407150-02007 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source CitationAsfar P, Meziani F, Hamel JF, et al; SEPSISPAM Investigators. High versus low blood-pressure target in patients with septic shock. N Engl J Med. 2014;370:1583-93. https://pubmed.ncbi.nlm.nih.gov/24635770Clinical Impact RatingsHospitalists: Infectious Disease: Critical Care: References1 Finfer S, Bellomo R, Boyce N, et al; SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350:2247-56. [PMID: 15163774] Google Scholar2 Finfer S, McEvoy S, Bellomo R, et al; SAFE Study Investigators. Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis. Intensive Care Med. 2011;37:86-96. [PMID: 20924555] Google Scholar3 Delaney AP, Dan A, McCaffrey J, Finfer S. The role of albumin as a resuscitation fluid for patients with sepsis: a systematic review and meta-analysis. Crit Care Med. 2011;39:386-91. [PMID: 21248514] Google Scholar4 Russell JA. Is there a good MAP for septic shock? N Engl J Med. 2014;370:1649-51. [PMID: 24635771] Google Scholar5 Dellinger RP, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637. [PMID: 23353941] Google Scholar Author, Article, and Disclosure InformationAffiliations: Massachusetts General Hospital, Boston, Massachusetts, USA (B.T.T.)This article was published at Annals.org on 1 July 2014. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoIn patients with severe sepsis, adding albumin to crystalloid solution did not reduce 28- or 90-day mortality B. Taylor Thompson Metrics 15 July 2014Volume 161, Issue 2Page: JC7KeywordsAlbuminsHypertensionResuscitationSafetySepsisVasopressors ePublished: 15 July 2014 Issue Published: 15 July 2014 CopyrightCopyright © 2014 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...

High versus Low Blood Pressure Target in Patients with Septic Shock

Targeting a mean arterial pressure (MAP) of 80 to 85 mm Hg in patients with septic shock undergoing resuscitation did not result in significant differences in mortality at 28 or 90 days when compared with targeting a MAP of 65 to 70 mm Hg.

Does our understanding of blood pressure targets in diabetics need rethinking?

For many years the main strategy in the treatment of arterial hypertension has been based on blood pressure targets. Those targets are the levels of blood pressure considered as the goals to be achieved with therapy because they are thought to represent the values below which the greatest clinical benefit of antihypertensive treatment is obtained. During recent years the traditional target of less than 140/90 mmHg was modified by ‘the lower, the better’ strategy, based on recommendations from many clinical guidelines suggesting that blood pressure should be decreased as much as tolerated. The intensified treatment approach was especially recommended for people with diabetes, in whom a stricter target of less than 130/80 mmHg was usually defined based on the idea that the combination of both conditions will possibly hasten the development and progression of complications [1]. However, all of these targets were based on observational or indirect data, and supported by scant evidence from prospective randomized trials [2]. Besides some concerns regarding the possibility of a J-curve phenomenon [3], ‘the lower, the better’ strategy was formally questioned in a Cochrane meta-analysis of randomized trials that showed no clinical benefits in mortality or cardiovascular morbidity when a lower blood pressure target was compared with the traditional target in the general population of individuals with hypertension [4]. Similar results have been obtained when the comparison was restricted to individuals with diabetes, with the only exceptions of a significant but quantitatively small reduction in strokes and a significant increase in other serious adverse events a ssociated with a lower systolic target [4–7]. Although not designed to test outcomes associated with different blood pressure targets, the results of some randomized trials including people with diabetes or “It can be argued that conventional blood pressure measurement has a poorer prognostic significance compared with other strategies that provide information on blood pressure variability during a certain period of time.”

High versus Low Blood-Pressure Target in Patients with Septic Shock

BackgroundThe Surviving Sepsis Campaign recommends targeting a mean arterial pressure of at least 65 mm Hg during initial resuscitation of patients with septic shock. However, whether this blood-pressure target is more or less effective than a higher target is unknown.MethodsIn a multicenter, open-label trial, we randomly assigned 776 patients with septic shock to undergo resuscitation with a mean arterial pressure target of either 80 to 85 mm Hg (high-target group) or 65 to 70 mm Hg (low-target group). The primary end point was mortality at day 28.ResultsAt 28 days, there was no significant between-group difference in mortality, with deaths reported in 142 of 388 patients in the high-target group (36.6%) and 132 of 388 patients in the low-target group (34.0%) (hazard ratio in the high-target group, 1.07; 95% confidence interval [CI], 0.84 to 1.38; P=0.57). There was also no significant difference in mortality at 90 days, with 170 deaths (43.8%) and 164 deaths (42.3%), respectively (hazard ratio, 1.04; 95% CI, 0.83 to 1.30; P=0.74). The occurrence of serious adverse events did not differ significantly between the two groups (74 events [19.1%] and 69 events [17.8%], respectively; P=0.64). However, the incidence of newly diagnosed atrial fibrillation was higher in the high-target group than in the low-target group. Among patients with chronic hypertension, those in the high-target group required less renal-replacement therapy than did those in the low-target group, but such therapy was not associated with a difference in mortality.ConclusionsTargeting a mean arterial pressure of 80 to 85 mm Hg, as compared with 65 to 70 mm Hg, in patients with septic shock undergoing resuscitation did not result in significant differences in mortality at either 28 or 90 days. (Funded by the French Ministry of Health; SEPSISPAM ClinicalTrials.gov number, NCT01149278.)

C-Reactive Protein as a Prognostic Marker After Lacunar Stroke

Inflammatory biomarkers predict incident and recurrent cardiac events, but their relationship to stroke prognosis is uncertain. We hypothesized that high-sensitivity C-reactive protein (hsCRP) predicts recurrent ischemic stroke after recent lacunar stroke. Levels of Inflammatory Markers in the Treatment of Stroke (LIMITS) was an international, multicenter, prospective ancillary biomarker study nested within Secondary Prevention of Small Subcortical Strokes (SPS3), a phase III trial in patients with recent lacunar stroke. Patients were assigned in factorial design to aspirin versus aspirin plus clopidogrel, and higher versus lower blood pressure targets. Patients had blood samples collected at enrollment and hsCRP measured using nephelometry at a central laboratory. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for recurrence risks before and after adjusting for demographics, comorbidities, and statin use. Among 1244 patients with lacunar stroke (mean age, 63.3±10.8 years), median hsCRP was 2.16 mg/L. There were 83 recurrent ischemic strokes (including 45 lacunes) and 115 major vascular events (stroke, myocardial infarction, and vascular death). Compared with the bottom quartile, those in the top quartile (hsCRP>4.86 mg/L) were at increased risk of recurrent ischemic stroke (unadjusted HR, 2.54; 95% CI, 1.30-4.96), even after adjusting for demographics and risk factors (adjusted HR, 2.32; 95% CI, 1.15-4.68). hsCRP predicted increased risk of major vascular events (top quartile adjusted HR, 2.04; 95% CI, 1.14-3.67). There was no interaction with randomized antiplatelet treatment. Among recent lacunar stroke patients, hsCRP levels predict the risk of recurrent strokes and other vascular events. hsCRP did not predict the response to dual antiplatelets. http://www.clinicaltrials.gov. Unique identifier: NCT00059306.

Hypertension in chronic kidney disease

Abstract CKD is leading cause of secondary hypertension. Prevalence of hypertension in Indian urban population is appox. 20–40% whereas in CKD its prevalence is much higher depending on stage of CKD reaching about 90% in ESRD. Hypertension, besides proteinuria is one of important factor in progression of CKD and CVD risk. Thus it has pivotal role in outcome of CKD and ESRD patients. Large number of studies has shown that effective control of blood pressure retards progression of renal disease and lower blood pressure targets have more favorable outcome, especially in proteinuric patients. The cardiovascular mortality is much higher in CKD than general population, but there are no large studies in CKD population to ascertain optimal blood pressure in reducing cardiovascular mortality in this group. The understanding of hypertension and target blood pressure level to be achieved in CKD and ESRD patients in terms of retarding the progression of renal disease and reducing the CVD events in this population has been discussed with the available evidences.

Management of the Spectrum of Essential Hypertension: A 2013 Perspective

Management of hypertension: The association of hypertension with cardiovascular and renal disease is continuous and independent of other risk factors. Despite the increase in awareness and treatment of hypertension in the past decade, less than 50% of adults in the U.S have adequate blood pressure control. Every 10% increase in the treatment of patients with hypertension could prevent an additional 14,000 deaths. This article reviews the latest evidence guiding current hypertension management. The main classes of drugs used to treat hypertension are diuretics (thiazides, loop and aldosterone antagonists), angiotensin converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, beta-blockers. Alpha-adrenergic blockers and direct renin inhibitors are used infrequently and are mostly used as the 4th or 5th added agent. No consensus has been established on initial drug choice. In patients with compelling indications, such as ischemic heart disease, diabetes, chronic kidney disease and stroke, some classes have shown greater benefits. Widely accepted is that blood pressure reduction is the most important determinant in lowering cardiovascular risk when there is no indication for a particular class of drugs. Hypertensive patients with central and peripheral vascular disease, chronic kidney disease and diabetes should have a lower target blood pressure. In patients with mild primary hypertension undergoing monotherapy, with inadequate blood pressure control, sequential monotherapy may be attempted prior to adding another drug. Combination therapy should be considered from the onset in individuals with blood pressures that exceed 20/10 mmHg above the set target range. The combination of angiotensin converting enzyme inhibitor plus a calcium channel blocker has been proven to be superior to other combinations. Considering the impact that adequate treatment can make in preventing deaths, the challenge is to improve access to care of patients with hypertension.

Is the lower blood pressure target for patients with chronic kidney disease supported by evidence?

Major guidelines recommend a blood pressure (BP) target of less than 130/80 mmHg for patients with chronic kidney disease (CKD) even though the optimal BP target in this population is unclear. This review summarizes the evidence on BP target in CKD and highlights recent pertinent publications. Clinical trials in CKD have not definitively shown that setting a BP target that is lower than the standard target of less than 140/90 mmHg provides additional benefit for important clinical outcomes. However, subgroup analyses from the recently published posttrial cohort of the African-American Study of kidney disease and a systematic review of BP target trials in CKD suggest that lower than the standard BP target may be beneficial in patients with proteinuria level of more than 300 or 1000 mg/day. Evidence supports a BP target of less than 140/90 mmHg in most patients with CKD. A lower target may be chosen in CKD patients with proteinuria after individualized risk-benefit assessment. Treatment to a lower target may require greater vigilance to monitor for and avoid possible symptoms and adverse events from hypotension.