Blood Pressure Targets

Still Struggling for the Right Answer

Magdy El-MasryProf. of CardiologyTanta University

Blood Pressure TargetsWhat Do the New Guidelines Say ?

Guidelines For Hypertension 2011-2014

A Flood of Hypertension Guidelines

Plethora of HTN guidelines

Oct 2011Oct 2014Jun 2013

US Hypertension Guideline Mania

Nov 2013

2014 20102012

Dec 2013Dec 2013

2014

The multitude of guidelines from respected professional bodies and

individuals have caused, in my opinion, needless confusion bordering on chaos.

C. Venkata S. Ram, MD The Journal of Clinical Hypertension Vol 16 | No 4 | April 2014

A Flurry of Guidelines for High Blood Pressure Management

“Flurry of guidelines, which offer different

recommendations on BP targets.”

*ADA: < 140/80

**KDIGO: <140/90 w/o albuminuria ≤130/80 if >30 mg/24hr

Hypertension Goals of Various Organizations

2014 CHEP

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The Joint National Committee (JNC )

JNC 7 recommended a treatment threshold of 140/90 mm Hg regardless of age, whereas JNC 8 raises the systolic threshold at age 60.

In addition, JNC 7 recommended a lower treatment threshold (130/80 mm Hg) for patients with diabetes or chronic kidney disease, but JNC 8 does not.

JNC 8 Has Finally ArrivedWhat's Changed : JNC 7 vs JNC 8

Controversy surrounds long-awaited JNC 8 guideline

The controversial JNC 8 relaxed BP goals from

140/90 to 150/90

Is JNC 8’s hypertension

treatment threshold too high ?

Blood pressure targets: are clinical guidelines wrong?

JNC 8 Headlines

Despite Controversy, JNC 8 Guideline Provides Much-needed Standards for Hypertension Management

The JNC 8 Hypertension Guidelines: An In-Depth Guide

A call to retract the JNC-8 hypertension guidelines

Hypertension Guidelines: Clear as Mud

AHA: JNC 8 Putting Older Adults at Risk?Analysis warns of potential harm from BP

guideline change.

New Analysis Questions Higher JNC 8's SBP Target

for Patients Over 60

Proportion of US Adults Potentially Affected by the 2014 Hypertension Guideline

JAMA. 2014;311(14):1424-1429.

If the JNC 8 recommendations are used, 6 million adults in the US aged 60 years and older would be ineligible for treatment with antihypertensive drugs,

and treatment intensity would be decreased for an additional 13.5 million older persons,

leading to increased incidences of coronary events, stroke, heart failure, cardiovascular mortality, and other adverse events associated with inadequate control of hypertension.

Impact of the 2014 Expert Panel Recommendations for Management of High Blood Pressure on Contemporary Cardiovascular Practice : Insights From the NCDR PINNACLE RegistryJ Am Coll Cardiol. 2014 Dec 2;64(21):2196-203

Of 1,185,253 patients in the study cohort, 706,859 (59.6%) achieved the 2003 JNC-7 goals. Using the 2014 recommendations, 880,378 (74.3%) patients were at goal.

Among U.S. ambulatory cardiology patients with hypertension, nearly 1 in 7 who did not meet JNC-7 recommendations would now meet the 2014 treatment goals.

NCDR, National Cardiovascular Data Registry; PINNACLE, Practice Innovation and Clinical Excellence

2014 Eighth Joint National Committee Panel Recommendation for Blood Pressure Targets Revisited :Results From the INVEST StudyJ Am Coll Cardiol. 2014;64(8):784-793.

The International Verapamil SR-Trandolapril Study (INVEST)

8,345 Patients 60 years of age or older with CAD and baseline SBP >150 mm Hg randomized to a treatment strategy on the basis of either atenolol/hydrochlorothiazide or verapamil-SR /trandolapril were categorized into 3 groups on the basis of achieved on-treatment SBP: group 1, <140 mm Hg; group 2, 140 to <150 mm Hg; and group 3, ≥150 mm Hg.

Date of download: 5/25/2015

Copyright © The American College of Cardiology. All rights reserved.

From: 2014 Eighth Joint National Committee Panel Recommendation for Blood Pressure Targets Revisited: Results From the INVEST Study

J Am Coll Cardiol. 2014;64(8):784-793. doi:10.1016/j.jacc.2014.05.044

Study Design and Main Outcomes

Patients who achieved a systolic blood pressure <140 mm Hg had the lowest rate of the primary outcome, cardiovascular mortality, and fatal and nonfatal stroke compared with the groups with achieved systolic blood pressure≥140 mm Hg. BP = blood pressure; CV = cardiovascular; INVEST= INternational VErapamil SR Trandolapril STudy; MI = myocardial infarction; SBP = systolic blood pressure.

Figure Legend:

In hypertensive patients with CAD who are ≥60 years of age, achieving a SBP target of 140 to <150 mm Hg as recommended by the JNC-8 panel was associated with less benefit than the previously recommended target of <140 mm Hg.

“New Hypertension Recommendations Anticipated in 2016”

The AHA and the ACC, in collaboration with nine other medical societies, will be releasing new hypertension guidelines that will serve as an update to those released by the JNC 7 in 2003.

Blood Pressure Targets in CAD Patients

JNC 8 : Simple but not complete

JNC 8 does not address the optimal treatmentof hypertension in patients with coronary artery disease

On March 31, 2015, the AHA, the ACC, and the ASH issued a new scientific statement entitled “Treatment of Hypertension in Patients with Coronary Heart Disease.”

Class/Level of Evidence Condition BP Goal (mmHg)

IIa/B Age >80 years < 150/90

I/AIIa/CIIa/B

CADACSHF

< 140/90

IIb/CIIb/C

CADPost-MI, stroke, TIA

CAD, PAD, AAA

< 130/80

BP Goals

March 31, 2015

Goals for target BP level or reduction from pretreatment baseline are uncertain and should be individualized, but it is reasonable to achieve a SBP<140 mm Hg and a DBP<90 mm Hg

(Class IIa; Level of Evidence B). For patients with a recent lacunar stroke, it might be

reasonable to target a SBP of <130 mm Hg (Class IIb;Level of Evidence B).

2014

There is no consensus among new HTN practice guidelines as to target treatment BP among various subpopulations of patients.

While most guidelines have a target BP < 140/90 for the general population, the JNC-8 task force favors a target BP < 150/90 mm Hg for persons age ≥ 60y.

Most guidelines now target a BP < 150/90 for

persons age ≥ 80y.

Most guidelines now target a BP < 140/90 for patients with diabetes or CKD, while a few others target a BP < 130/80 if diabetes, albuminuria, or high stroke risk is present.

What are the current blood pressure targets?

BP goals in patients with CADAHA/ACC/ASH 2015

• The <140/90 mm Hg BP target is reasonable for the secondary prevention of CVD in patients with hypertension and CAD.

• A lower target BP of <130/80 mm Hg may be appropriate in some individuals with CAD or those with previous MI, stroke, or transient ischemic attack, or CAD risk equivalents (carotid artery disease, peripheral arterial disease, or abdominal aortic aneurysm).

• A BP goal of <150/90 mm Hg is recommended in those who are >80 years of age