What is the Target BP for Hypertensive Patients?
With hypertension present in approximately 40 percent of adults in the U.S. and accounting for 41 percent of all cardiovascular disease deaths, discussions among cardiologists have continued to question the most appropriate target blood pressures (BP) in the treatment of diagnosed patients. While some observations have concluded that lowering BP along a linear axis will correspond with a proportionate decrease in risk, others have shown that aggressive BP lowering has been associated with worsened outcomes, suggesting a more J-shaped curve.
A retrospective cohort study published Aug. 4 in the Journal of the American College of Cardiology, evaluated the discrete ranges of achieved BP and subsequent risk for mortality and end-stage renal disease and found that “treated hypertension patients with BP in the range of 130 to 139 mm Hg systolic and 60 to 79 mm Hg diastolic experienced the lowest risk for the composite outcome of mortality and end-stage renal disease.”
The study was led by John Sim, MD, Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, and evaluated 398,419 hypertensive individuals within the Kaiser Permanente Southern California health system from Jan. 1, 2006 through Dec. 31, 2010. Mortality occurred in 25,182 individuals (6.3 percent) and end-stage renal disease occurred in 4,957 individuals (1.2 percent).
Results showed a significant J-shaped association between actual, treated BP levels and adverse outcomes. While the lowest risk of the composite outcomes was a systolic BP of 137 mm Hg and a diastolic BP of 71 mm Hg, BP that was either higher or lower than 130 to 139 mm Hg systolic and 60 to 79 mm Hg diastolic were associated with increased risk of the composite endpoint.
Despite these findings, the authors ultimately conclude that the setting of the ideal BP targets in the hypertension population has still not been satisfactorily addressed. “Whereas current U.S. guidelines emphasize the upper limits of therapeutic goals, the potential dangers of overtreatment may need to be considered. In the current hypertension management environment, both escalation and withdrawal of medications may be appropriate for optimal outcomes in a hypertension population,” the authors conclude.
In a commenting editorial Charlotte Andersson, MD, PHD, and Ramachandran Vasan, MD, attribute this continued inconclusiveness to the fact that optimal BP targets may simply vary for different patient groups, influences by varying comorbidities and other risk factors. “Ultimately, we need further studies to establish the optimal BP treatment target for individuals with various comorbidities,” they write. “It may make sense to treat younger people with less comorbidity more aggressively than older individuals or people with a large burden of comorbidity, but the exact numerical BP targets are yet to be determined. Clinical trial results would provide a more definitive answer than observational analyses will, even analyses of very large datasets.”
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