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High Blood Pressure: How Low Should We Go?

Tuesday, September 15, 2015 // Uncategorized

How low she one’s blood pressure be when being treated for hypertension?  That question has been debated for decades.  The last updated guidelines were in late 2014.  They created controversy by raising the optimal levels in patients 60 and over.  Here is a summary from Journal Watch:

December 30, 2014 JNC 8: Raising the Blood Pressure (and Ire) of Many Jamaluddin Moloo, MD, MPH Jamaluddin Moloo, MD, MPH

The Joint National Committee recommends that patients older than 60 be treated for hypertension only when systolic blood pressure exceeds 150 mm Hg. Jamaluddin Moloo, MD, MPHThe Joint National Committee (JNC) 8 guideline (published online in late December 2013 and printed in a February 2014 issue of JAMA) addresses blood pressure (BP) thresholds at which drug therapy should be initiated, BP targets during hypertensive treatment, and choice of antihypertensive agents (NEJM JW Gen Med Dec 24 2013).For patients younger than 60, JNC 8 specifies that drug therapy should be considered when diastolic BP is >90 mm Hg or systolic BP is >140 mm Hg. For older patients (age, ≥60), the diastolic BP threshold remains >90 mm Hg, but the systolic BP threshold is >150 mm Hg. Among people with diabetes or chronic renal disease, the threshold to initiate drug therapy is 140/90 mm Hg, and the goal for treatment is <140/90.In black patients, initial drug choices include thiazide-type diuretics or calcium-channel blockers (CCBs); in nonblack patients, initial drug choices were expanded (relative to JNC 7 recommendations) to include not just thiazide-type diuretics, but also CCBs, angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) — but not β-blockers. JNC 8 recommends that patients with chronic renal disease generally should be prescribed ACE inhibitors or ARBs.Compared with the JNC 7 writers, the JNC 8 writing committee drew its conclusions more strictly from randomized-trial evidence and limited the scope of the guideline to drug therapy for hypertension. The most controversial and contested recommendation is the higher threshold (systolic BP, >150 mm Hg) for people older than 60. Some experts, and the American Society of Hypertension, recommend a target this high only for patients older than 80 (NEJM JW Gen Med Dec 24 2013). – See more at: http://www.jwatch.org/na36491/2014/12/30/jnc-8-raising-blood-pressure-and-ire-many#sthash.xG89nuBp.dpuf

 

Now the latest salvo comes from the NIH and a study that was stopped prematurely.  They issued a press release describing the results.  The problem is that it hasn’t yet be published and subjected to scrutiny as occurs with important clinical trials.  Here is the article from the New York Times:

 

Lower Blood Pressure Guidelines Could Be ‘Lifesaving,’ Federal Study Says

September 14, 2015 NIH: Aggressive Blood Pressure Management May Cut CV Events, Save Lives By Amy Orciari Herman Edited by André Sofair, MD, MPH

Reducing systolic blood pressure to below currently recommended targets may lower risk for cardiovascular events and death, according to findings from the NIH-funded SPRINT study announced on Friday.Some 9300 hypertensive adults aged 50 and older who were at high risk for heart disease or had kidney disease were randomized to one of two systolic BP targets: an aggressive target below 120 mm Hg, or a more conventional target below 140 mm Hg. Patients with diabetes or prior stroke were excluded.Participants were randomized between 2010 and 2013, and the trial was expected to go until 2017, but the researchers stopped it early after seeing the benefits of the intensive strategy. In that group, the risk for cardiovascular events was cut by nearly a third, and the mortality risk by almost a fourth, relative to conventional treatment.NEJM Journal Watch Cardiology’s Dr. Harlan Krumholz said: “Kudos to the NIH and the investigators for delivering on a challenging trial in this controversial area.The challenge for doctors and patients is to have patience because we only have the announcement at this point and lack the details to know how best to translate the study into practice.” – See more at: http://www.jwatch.org/fw110623/2015/09/14/nih-aggressive-blood-pressure-management-may-cut-cv#sthash.0r5DVThj.dpuf

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