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| {{CMG}}; '''Deputy Editor-In-Chief ''' {{RGB}} | | {{CMG}}; '''Deputy Editor-In-Chief ''' {{RGB}} |
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| The 24-hour ambulatory systolic pressure may better predict mortality than the daytime systolic blood pressure.<ref name="pmid29669232">{{cite journal| author=Banegas JR, Ruilope LM, de la Sierra A, Vinyoles E, Gorostidi M, de la Cruz JJ et al.| title=Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality. | journal=N Engl J Med | year= 2018 | volume= 378 | issue= 16 | pages= 1509-1520 | pmid=29669232 | doi=10.1056/NEJMoa1712231 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29669232 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=30361327 Review in: BMJ Evid Based Med. 2019 Jun;24(3):114-115] </ref> | | The 24-hour ambulatory systolic pressure may better mortality than the daytime systolic blood pressure. |
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| Regarding the accuracy of office oscillometric and home blood pressure monitoring compared with ambulatory blood pressure monitoring, a meta-analysis by the Rational Clinical Examination found<ref name="VieraYano2021">{{cite journal|last1=Viera|first1=Anthony J.|last2=Yano|first2=Yuichiro|last3=Lin|first3=Feng-Chang|last4=Simel|first4=David L.|last5=Yun|first5=Jonathan|last6=Dave|first6=Gaurav|last7=Von Holle|first7=Ann|last8=Viera|first8=Laura A.|last9=Shimbo|first9=Daichi|last10=Hardy|first10=Shakia T.|last11=Donahue|first11=Katrina E.|last12=Hinderliter|first12=Alan|last13=Voisin|first13=Christiane E.|last14=Jonas|first14=Daniel E.|title=Does This Adult Patient Have Hypertension?|journal=JAMA|volume=326|issue=4|year=2021|pages=339|issn=0098-7484|doi=10.1001/jama.2021.4533}}</ref>: | | Regarding the accuracy of office oscillometric and home blood pressure monitoring compared with ambulatory blood pressure monitoring, a meta-analysis by the Rational Clinical Examination found<ref name="pmid34313682">{{cite journal| author=Viera AJ, Yano Y, Lin FC, Simel DL, Yun J, Dave G | display-authors=etal| title=Does This Adult Patient Have Hypertension?: The Rational Clinical Examination Systematic Review. | journal=JAMA | year= 2021 | volume= 326 | issue= 4 | pages= 339-347 | pmid=34313682 | doi=10.1001/jama.2021.4533 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34313682 }} </ref>: |
| * Office pressures (presumably attended by medical personnel) has sensitivity and specificity of 51% and 88% | | * Office pressures (presumably attended by medical personnel) has sensitivity and specificity of 51% and 88% |
| * Home monitoring has sensitivity and specificity of 75% and 76% | | * Home monitoring has sensitivity and specificity of 75% and 76% |
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| Elevated high-sensitivity cardiac troponin T (hscTnT) and N-terminal pro-B-type natriuretic peptide (NTproBNP) levels may help guide treatment<ref name="pmid34468696">{{cite journal| author=Berry JD, Nambi V, Ambrosius WT, Chen H, Killeen AA, Taylor A | display-authors=etal| title=Associations of High-Sensitivity Troponin and Natriuretic Peptide Levels With Outcomes After Intensive Blood Pressure Lowering: Findings From the SPRINT Randomized Clinical Trial. | journal=JAMA Cardiol | year= 2021 | volume= 6 | issue= 12 | pages= 1397-1405 | pmid=34468696 | doi=10.1001/jamacardio.2021.3187 | pmc=8411355 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34468696 }} </ref>. | | Elevated high-sensitivity cardiac troponin T (hscTnT) and N-terminal pro-B-type natriuretic peptide (NTproBNP) levels may help guide treatment. |
| | |
| | The decision to treat may be affected by projected longevity of a patient<ref name="pmid35532917">{{cite journal| author=Chen T, Shao F, Chen K, Wang Y, Wu Z, Wang Y | display-authors=etal| title=Time to Clinical Benefit of Intensive Blood Pressure Lowering in Patients 60 Years and Older With Hypertension: A Secondary Analysis of Randomized Clinical Trials. | journal=JAMA Intern Med | year= 2022 | volume= | issue= | pages= | pmid=35532917 | doi=10.1001/jamainternmed.2022.1657 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35532917 }} </ref>: |
| | * "for patients 60 years and older with hypertension, intensive BP treatment may be appropriate for some adults with a life expectancy of greater than 3 years |
| | * "but may not be suitable for those with less than 1 year." |
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| ==Clinical practice guidelines== | | ==Clinical practice guidelines== |
| Recommendations for treatment goals from recent [[clinical practice guideline]]s are tabulated below. However, treated based on underlying risk rather than a blood pressure target may be more effective<ref name="pmid25131978">{{cite journal| author=Blood Pressure Lowering Treatment Trialists' Collaboration| title=Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. | journal=Lancet | year= 2014 | volume= 384 | issue= 9943 | pages= 591-598 | pmid=25131978 | doi=10.1016/S0140-6736(14)61212-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25131978 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=255TICafgdf06877 Review in: Ann Intern Med. 2014 Dec 16;161(12):JC5] [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25534965 Review in: Evid Based Med. 2015 Feb;20(1):21] </ref>. The logic supporting a target of 130/80 mm Hg has been disputed<ref name="pmid29357397">{{cite journal| author=Wilt TJ, Kansagara D, Qaseem A, Clinical Guidelines Committee of the American College of Physicians| title=Hypertension Limbo: Balancing Benefits, Harms, and Patient Preferences Before We Lower the Bar on Blood Pressure. | journal=Ann Intern Med | year= 2018 | volume= 168 | issue= 5 | pages= 369-370 | pmid=29357397 | doi=10.7326/M17-3293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29357397 }} </ref> and the Cochrane Collaboration found insufficient evidence to determine a treatment goal for adults<ref name="pmid30027631">{{cite journal| author=Saiz LC, Gorricho J, Garjón J, Celaya MC, Erviti J, Leache L| title=Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. | journal=Cochrane Database Syst Rev | year= 2018 | volume= 7 | issue= | pages= CD010315 | pmid=30027631 | doi=10.1002/14651858.CD010315.pub3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30027631 }} </ref> or adults over 65 years of age<ref name="pmid28787537">{{cite journal| author=Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM| title=Blood pressure targets for hypertension in older adults. | journal=Cochrane Database Syst Rev | year= 2017 | volume= 8 | issue= | pages= CD011575 | pmid=28787537 | doi=10.1002/14651858.CD011575.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28787537 }} </ref>. | | Recommendations for treatment goals from recent [[clinical practice guideline]]s are tabulated below. However, treated based on underlying risk rather than a blood pressure target may be more effective. The logic supporting a target of 130/80 mm Hg has been disputed and the Cochrane Collaboration found insufficient evidence to determine a treatment goal for adults or adults over 65 years of age. |
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| If the goal is 130/80, proper measurement includes (distilled from Table 8 of the ACC/AHA guidelines<ref name="pmid29133356">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2017 | volume= | issue= | pages= | pmid=29133356 | doi=10.1161/HYP.0000000000000065 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133356 }} </ref>, executive summary<ref name="pmid29133354">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2017 | volume= | issue= | pages= | pmid=29133354 | doi=10.1161/HYP.0000000000000066 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133354 }} </ref>): | | If the goal is 130/80, proper measurement includes (distilled from Table 8 of the ACC/AHA guidelines, executive summary): |
| * having the patient sit quietly for 5 minutes before a reading is taken | | * having the patient sit quietly for 5 minutes before a reading is taken |
| * supporting the limb used to measure BP | | * supporting the limb used to measure BP |
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| * a single reading is inadequate for clinical decision-making. An average of 2 to 3 BP measurements obtained on 2 to 3 separate occasions will minimize random error and provide a more accurate basis for estimation of BP. | | * a single reading is inadequate for clinical decision-making. An average of 2 to 3 BP measurements obtained on 2 to 3 separate occasions will minimize random error and provide a more accurate basis for estimation of BP. |
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| If the above measurement methods are not use, a preliminary study from [https://thrive.kaiserpermanente.org/care-near-you/northern-california/ Kaiser Northern California] suggests a target of 140 mm Hg<ref>{{cite journal|doi=10.1161/circ.136.suppl_1.14468 | author=Go AS | title = Impact of SPRINT-Based Blood Pressure Levels on Clinical Outcomes in a Large, Community-Based Population: The Kaiser Permanente Experience | journal = Circulation | year = 2018 | url = https://www.ahajournals.org/doi/abs/10.1161/circ.136.suppl_1.14468}}</ref>. | | If the above measurement methods are not use, a preliminary study from [https://thrive.kaiserpermanente.org/care-near-you/northern-california/ Kaiser Northern California] suggests a target of 140 mm Hg. |
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|
| {| class="wikitable" | | {| class="wikitable" |
| |+ AHA<ref name="pmid29133356">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2018 | volume= 71 | issue= 6 | pages= e13-e115 | pmid=29133356 | doi=10.1161/HYP.0000000000000065 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133356 }} </ref> vs Roerecke<ref name="pmid30715088">{{cite journal| author=Roerecke M, Kaczorowski J, Myers MG| title=Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension: A Systematic Review and Meta-analysis. | journal=JAMA Intern Med | year= 2019 | volume= 179 | issue= 3 | pages= 351-362 | pmid=30715088 | doi=10.1001/jamainternmed.2018.6551 | pmc=6439707 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30715088 }} </ref> estimates of relationship between routine, auscultated BP measurement and gold standard ambulatory measurement. | | |+ AHA vs Roerecke estimates of relationship between routine, auscultated BP measurement and gold standard ambulatory measurement. |
| ! Clinic (routine)
| |
| AHA, 2017<ref name="pmid29133356"/>
| |
| ! Clinic (routine) | | ! Clinic (routine) |
| Roerecke, 2018<ref name="pmid30715088"/>
| |
| ! style="font-weight:bold;" | Clinic (automated)
| |
| Roerecke, 2018<ref name="pmid30715088"/>
| |
| ! style="font-weight:bold;" | Home (self)
| |
| AHA, 2017 | | AHA, 2017 |
| ! style="font-weight:bold;" | Daytime, ambulatory †
| |
| ! Nighttime ambulatory
| |
| AHA, 2017<ref name="pmid29133356"/>
| |
| ! 24 hour ambulatory<ref name="pmid30715088"/>
| |
| AHA, 2017<ref name="pmid29133356"/><ref name="pmid29133356"/> †
| |
| |-
| |
| | style="text-align: center;" | 120/80
| |
| | style="text-align: center;" | 125/82
| |
| | style="text-align: center; background-color:#9aff99;" | 120/80
| |
| | style="text-align: center; background-color:#9aff99;" | 120/80
| |
| | style="text-align: center; background-color:#9aff99;" | 120/80
| |
| | style="text-align: center;" | 100/65
| |
| | style="text-align: center;" | 115/75
| |
| |-
| |
| | style="text-align: center;" | 130/80
| |
| | style="text-align: center;" | 145/85
| |
| | style="text-align: center; background-color:#9aff99;" | 130/80
| |
| | style="text-align: center; background-color:#9aff99;" | 130/80
| |
| | style="text-align: center; background-color:#9aff99;" | 130/80
| |
| | style="text-align: center;" | 110/65
| |
| | style="text-align: center;" | 125/75
| |
| |-
| |
| | style="text-align: center;" | 140/90
| |
| | style="text-align: center;" | 150/90
| |
| | style="text-align: center; background-color:#9aff99;" | 135/85
| |
| | style="text-align: center; background-color:#9aff99;" | 135/85
| |
| | style="text-align: center; background-color:#9aff99;" | 135/85
| |
| | style="text-align: center;" | 120/70
| |
| | style="text-align: center;" | 130/80
| |
| |-
| |
| | style="text-align: center;" | 160/100
| |
| | style="text-align: center;" | 160/95
| |
| | style="text-align: center; background-color:#9aff99;" | 145/90
| |
| | style="text-align: center; background-color:#9aff99;" | 145/90
| |
| | style="text-align: center; background-color:#9aff99;" | 145/90
| |
| | style="text-align: center;" | 140/85
| |
| | style="text-align: center;" | 145/90
| |
| |-
| |
| | colspan="7" | Notes:<br/>
| |
| † The IDACO Investigators found that the 24-hour ambulatory systolic pressure may better predict mortality than the daytime systolic blood pressure.<ref name="pmid31386134">{{cite journal| author=Yang WY, Melgarejo JD, Thijs L, Zhang ZY, Boggia J, Wei FF | display-authors=etal| title=Association of Office and Ambulatory Blood Pressure With Mortality and Cardiovascular Outcomes. | journal=JAMA | year= 2019 | volume= 322 | issue= 5 | pages= 409-420 | pmid=31386134 | doi=10.1001/jama.2019.9811 | pmc=6822661 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31386134 }} </ref>
| |
| |}
| |
|
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| It is cost-effective to treatment stage 1 hypertension in men of all ages and everyone over age 60<ref name="pmid33342242">{{cite journal| author=Constanti M, Floyd CN, Glover M, Boffa R, Wierzbicki AS, McManus RJ| title=Cost-Effectiveness of Initiating Pharmacological Treatment in Stage One Hypertension Based on 10-Year Cardiovascular Disease Risk: A Markov Modeling Study. | journal=Hypertension | year= 2021 | volume= 77 | issue= 2 | pages= 682-691 | pmid=33342242 | doi=10.1161/HYPERTENSIONAHA.120.14913 | pmc=7803450 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33342242 }} </ref>.
| |
| * In this study, cost-effective was defined by the [[National Guideline Centre for the National Institute for Health and Care Excellence]] (NICE) which uses the threshold of £20,000 (about $27,000 U.S.).
| |
| * For women less than age 60, treatment was cost-effective if risk was increased.
| |
|
| |
| {| class="wikitable"
| |
| |+ Practice guidelines comparison<ref name="pmid29133354">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al.| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2018 | volume= 71 | issue= 6 | pages= 1269-1324 | pmid=29133354 | doi=10.1161/HYP.0000000000000066 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133354 }} </ref><ref name="pmid33910363">{{cite journal| author=Jones DW, Whelton PK, Allen N, Clark D, Gidding SS, Muntner P | display-authors=etal| title=Management of Stage 1 Hypertension in Adults With a Low 10-Year Risk for Cardiovascular Disease: Filling a Guidance Gap: A Scientific Statement From the American Heart Association. | journal=Hypertension | year= 2021 | volume= 77 | issue= 6 | pages= e58-e67 | pmid=33910363 | doi=10.1161/HYP.0000000000000195 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33910363 }} </ref><ref name="pmid28135725">{{cite journal| author=Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA et al.| title=Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. | journal=Ann Intern Med | year= 2017 | volume= 166 | issue= 6 | pages= 430-437 | pmid=28135725 | doi=10.7326/M16-1785 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28135725 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=28418540 Review in: Ann Intern Med. 2017 Apr 18;166(8):JC38] </ref><ref name="pmid24352797">{{cite journal| author=James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J et al.| title=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). | journal=JAMA | year= 2014 | volume= 311 | issue= 5 | pages= 507-20 | pmid=24352797 | doi=10.1001/jama.2013.284427 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24352797 }} </ref>
| |
| |-
| |
| !
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| ! Goal < 60 years old
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| ! Goal >= 60 years old
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| ! High risk
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| |-
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| | JNC-8, 2014<ref name="pmid24352797"/>
| |
| | 140/90
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| | 150/90*
| |
| |
| |
| |-
| |
| | ACP/AAFP, 2017<ref name="pmid28135725"/>
| |
| | Not applicable
| |
| | 150 or 140 if high risk
| |
| |
| |
| |-
| |
| | [https://www.ncqa.org/hedis/measures/controlling-high-blood-pressure/ HEDIS] and [https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_236_MIPSCQM.pdf MIPS] QI Measures
| |
| | colspan="3" |< 140/90
| |
| |-
| |
| |-
| |
| | Kaiser, 2019<ref>Kaiser (2019). Adult Blood Pressure. Available at http://kpcmi.org/how-we-work/guidelines/</ref>
| |
| | colspan="2" |140/90
| |
| | Kaiser states "In adults with ASCVD, CKD, age > 75 years, or 10-year ASCVD risk > 10%, consider treating to a goal SBP of < 130 mm Hg"<br/>
| |
| This is consistent with more agressive treatment in the SPRINT trial<ref name="pmid26551272"/>.
| |
| |-
| |
| | [[2017 ACC/AHA Hypertension Guidelines|AHA/ACC/others]], 2017<ref name="pmid29133354"/>2021<ref name="pmid33910363"/>
| |
| | colspan="2" | < 130/80† if remains above goal for 3-6 months<ref name="pmid33910363"/>
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| | If ASCVD or 10-year CVD risk ≥10%: "Start with both nonpharmacologic and pharmacologic therapy. Reassess BP in 1 month."<ref name="pmid33910363"/>
| |
| |-
| |
| | colspan="4" | '''Notes:'''
| |
| * Treat to 140/90 if age >=60 with DMII or CKD.<br/>
| |
| † Treat if > 140/90 or 130/80 if high risk which is defined as existing cardiovascular disease, 10-year cardiovascular risk ≥10%, diabetes, or CKD.
| |
| |}
| |
|
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| ==Newer trials==
| |
|
| |
| Newer [[randomized controlled trial]]s have identified conflicting benefits to more intensive therapy.
| |
| {| class="wikitable"
| |
| |+ Randomized controlled trials of lower treatment goals
| |
| ! rowspan="2" |
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| ! colspan="3" | Patients
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| ! rowspan="2" | BP target in intervention
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| ! rowspan="2" | Final BP in intervention
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| ! rowspan="2" | Primary outcome (composite)<br/>(Hazard ratio)
| |
| |-
| |
|
| |
| ! Baseline blood pressure
| |
|
| |
| ! Estimated cardiac risk<br/>([https://openrules.ocpu.io/home/www/statins_for_cvd.html calculated with pooled cohort equation])
| |
|
| |
| ! Outcome rate in the control
| |
| |-
| |
| | ACCORD, 2010<ref name="pmid20228401"/>
| |
| | 140/76
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| | All patients were diabetic<br/>9% for anglo women and 23% for anglo men
| |
| | 2.1% per year
| |
| | SBP 120 vs 140
| |
| | 119/64
| |
| | 0.88 (95% CI: 0.73 to 1.06)
| |
| |-
| |
| | SPRINT, 2015<ref name="pmid26551272"/>
| |
| | 140/78
| |
| | No diabetics<br/>16% for anglo women and 23% for anglo men (20% overall)
| |
| | 2.2% per year
| |
| | SBP 120 vs 140
| |
| | 121/67
| |
| | 0.75 (95% CI: 0.64 to 0.89)
| |
| |-
| |
| | HOPE-3, 2016<ref name="pmid27039945"/>
| |
| | 138/82
| |
| | 16% for anglo women and 23% for anglo men
| |
| | 1.7% per year*
| |
| | No target BP.<br/>Intervention all received candesartan 16 mg per day plus hydrochlorothiazide 12.5 mg per day
| |
| | 128/76
| |
| | 0.93 (95% CI: 0.79 to 1.10)
| |
| |-
| |
| | colspan="7" | Notes:
| |
| * 1.7% is the sum of the two co-primary outcomes. The HOPE-3 also reported 4.4% over 5.6 years.
| |
| |}
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| * In the ACCORD (Action to Control Cardiovascular Risk in Diabetes) [[randomized controlled trial]] patients with average blood pressure of 140/76 mm Hg ''and diabetes'' did ''not'' benefit from targeting a systolic blood pressure of less than 120 mm Hg (average 119/64 mm Hg), as compared with less than 140 mm Hg.<ref name="pmid20228401">{{cite journal| author=ACCORD Study . Cushman WC, Evans GW, Byington RP, Goff DC, Grimm RH et al.| title=Effects of intensive blood-pressure control in type 2 diabetes mellitus. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 17 | pages= 1575-85 | pmid=20228401 | doi=10.1056/NEJMoa1001286 | pmc=4123215 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20228401 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20667901 Review in: Evid Based Med. 2010 Oct;15(5):142-3] [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643982 Review in: Ann Intern Med. 2010 Jul 20;153(2):JC1-4, JC1-5] </ref>
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| ** Assuming the average patient in this trial was a nonsmoker and was diabetic, the estimated 10-year cardiovascular risk is 9% for anglo women and 23% for anglo men.
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| * In the SPRINT [[randomized control trial]], patients with an average blood pressure of 140/78 mm Hg and at ''high risk'' for CVD but who do not have a history of stroke or diabetes, intensive BP control (target SBP <120 mm Hg) that lowered systolic blood pressure to an average of 121/67 mm Hg ''improved'' CV outcomes and overall survival compared to standard therapy, while modestly increasing the risk of some serious adverse events<ref name="pmid26551272">{{cite journal| author=SPRINT Research . Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM et al.| title=A Randomized Trial of Intensive versus Standard Blood-Pressure Control. | journal=N Engl J Med | year= 2015 | volume= 373 | issue= 22 | pages= 2103-16 | pmid=26551272 | doi=10.1056/NEJMoa1511939 | pmc=4689591 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26551272 }} </ref>.
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| ** Assuming the average patient in this trial was not diabetic, 50% were smokers (per their publication)), 33% were women, and LDL was 113 (per their publication Friedrwald estimate is 191 - 53 - 125/5)) the estimated 10-year cardiovascular risk is 12% for anglo women and 20% for anglo men.
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| ** The [[number needed to treat]] (NNT), is about 200 (185) for the primary outcome (1.65% vs 2.19%) by dropping the systolic pressure by 15 mm Hg.
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| * In the HOPE-3 trial [[randomized controlled trial]], patients with an average blood pressure of 138/82 mm HG and with intermediate risk who did not have cardiovascular disease lowering systolic blood pressure to an average of 128 mm Hg was ''insignificantly'' beneficial. <ref name="pmid27039945">{{cite journal| author=Yusuf S, Lonn E, Pais P, Bosch J, López-Jaramillo P, Zhu J et al.| title=Blood-Pressure and Cholesterol Lowering in Persons without Cardiovascular Disease. | journal=N Engl J Med | year= 2016 | volume= 374 | issue= 21 | pages= 2032-43 | pmid=27039945 | doi=10.1056/NEJMoa1600177 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27039945 }} </ref>
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| ** Assuming the average patients in this trial was a nonsmoker and not diabetic, the estimated 10-year cardiovascular risk is 10% for anglo women and 19% for anglo men.
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| ** Benefit was found in a subgroup analysis of patients with systolic blood pressure above 144 mm Hg (mean 154 mm Hg).
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| Debate exists on how low should physicians target blood pressure in their patients especially in light of studies that have shown a J or U-shaped curve phenomenon associated with hypertension treatment where low and very high blood pressure values are associated with increased risk of cardiovascular events.<ref name="pmid20846991">{{cite journal| author=Bangalore S, Messerli FH, Wun CC, Zuckerman AL, DeMicco D, Kostis JB et al.| title=J-curve revisited: An analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial. | journal=Eur Heart J | year= 2010 | volume= 31 | issue= 23 | pages= 2897-908 | pmid=20846991 | doi=10.1093/eurheartj/ehq328 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20846991 }} </ref> A less strict target in diabetic and elderly patients is in the new ADA and ESH/ESC 2013 [[clinical practice guideline]]s respectively. This rationale is supported by the fact that lower SBP targets in diabetic patients have not been shown to generate better outcomes.<ref name="pmid23264423">{{cite journal| author=| title=Summary of revisions for the 2013 clinical practice recommendations. | journal=Diabetes Care | year= 2013 | volume= 36 Suppl 1 | issue= | pages= S3 | pmid=23264423 | doi=10.2337/dc13-S003 | pmc=PMC3537268 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23264423 }} </ref> Similarly, treatment of stage 1 hypertension in elderly patients and targeting SBP values to <140 mmHg have not been well substantiated and may sometimes carry more risk than benefit.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 | doi=10.1097/HJH.0b013e328364ca4c | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref>
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| ==References==
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| {{reflist|2}}
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| {{WH}}
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| {{WS}}
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| [[Category:Aging-associated diseases]]
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| [[Category:Cardiology]]
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| [[Category:Emergency medicine]]
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| [[Category:Cardiovascular diseases]]
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| [[Category:Medical conditions related to obesity]]
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| [[Category:Nephrology]]
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| [[Category:Up-To-Date]]
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| [[Category:Up-To-Date cardiology]]
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| [[Category:Cardiology board review]]
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