What should the blood pressure treatment goal be in adults with hypertension in 2016?

On the basis of randomized clinical trial data including the Hypertension in the Very Elderly (HYVET) trial (1) and the Systolic Hypertension in the Elderly (SHEP) trial (2-4), the American College of Cardiology Foundation/ American Heart Association 2011 hypertension guidelines (5), the European Society of Hypertension/European Society of Cardiology 2013 hypertension guidelines (6), the 2014 American Society of Hypertension/International Society of Hypertension guidelines (7), and the American Heart Association/American College of Cardiology Foundation/American Society of Hypertension 2015 guidelines on treatment of hypertension in adults with coronary artery disease (8) recommended that the blood pressure be lowered to less than 140/90 mmHg in adults younger than 80 years and to less than 150/90 mmHg in adults aged 80 years and older. Data from 9,787 adults in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study also supported these recommendations (9).

The 2013 Eighth Joint National Committee (JNC 8) guidelines for management of hypertension recommended lowering the blood pressure in adults aged 60 years or older to less than 150/90 mmHg if they did not have diabetes mellitus or chronic kidney disease and to less than 140/90 mmHg if they had diabetes mellitus or chronic kidney disease (10). These guidelines were not endorsed by any professional societies. The minority view from JNC 8 recommended lowering the blood pressure in adults aged 60 years and older with hypertension to less than 140/90 mmHg (11).

The new guidelines for the treatment of hypertension will be strongly influenced by the results from the Systolic Blood Pressure Intervention Trial (SPRINT) (12,13). SPRINT randomized 9,361 adults with a systolic blood pressure of 130–180 mmHg and an increased cardiovascular risk but without diabetes mellitus, history of stroke, symptomatic heart failure within the past 6 months, a left ventricular ejection fraction of less than 35%, and an estimated glomerular filtration rate less than 20 mL/min/1.73 m² to a systolic blood pressure goal of less than 120 mmHg or less than 140 mmHg. Of the 9,361 adults aged 50 years and older, 2,636 (28.2%) were aged 75 years and older (mean age 79.9 years) (12). Of the patients aged 75 years and older, 30.9% were frail (13).

The primary composite outcome of myocardial infarction, other acute coronary syndrome, stroke, heart failure, or death from cardiovascular causes was decreased 25% by intensive blood pressure treatment in the whole group (12) and by 34% in adults aged 75 years and older. All-cause mortality was decreased by 27% by intensive blood pressure treatment in the whole group (12) and by 33% in adults aged 75 years and older (13). Heart failure was decreased by intensive blood pressure treatment 38% in the whole group (12) and by 38% in adults aged 75 years and older (13). On the basis of these data and other clinical trial data, I recommend a blood pressure treatment goal of less than 120/80 mmHg in high-risk adults such as those treated in SPRINT. The 2016 Canadian viewpoint also recommends a systolic blood pressure goal of less than 120 mmHg in these high-risk persons (14).

Expert medical opinion will have to be used to recommend what the optimal blood pressure goal should be in adults with hypertension not included in the SPRINT trial. On the basis of data from the ACTION to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD BP) trial (5-17), this author recommends treating older adults with diabetes mellitus at increased cardiovascular risk to a blood pressure treatment goal of less than 130/80 mmHg or to less than 120/80 mmHg with more intensive monitoring for serious adverse events (18).

Randomized clinical trial data are needed to determine the optimal blood pressure goal in persons with hypertension not included in the SPRINT trial. Until these data are available, on the basis of the available clinical trial data, my expert medical opinion recommends treating adults with heart failure with reduced or preserved left ventricular ejection fraction, adults with a left ventricular ejection fraction below 35%, adults with a history of stroke or transient ischemic attack, and adults with an estimated glomerular filtration rate less than 20 mL/min/1.73 m² to a blood pressure goal of less than 130/80 mmHg.