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Bryan Williams, Professor and Chair of Medicine, University College London, UK, talks to Cardio Debate about the guidelines of high blood pressure treatment, how they compare in different countries, and the recent debate about high pressure goals.
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Guidelines and goal blood pressure in patients with cardiovascular disease: What is your recommendation regarding goals to achieve?
There has been a lot of debate about how low we should lower blood pressure. I think the thing that’s clear is the conventional target across most guidelines in the world is less than 140/90 mm Hg. So we try and get everyone’s blood pressure on treatment below 140/90 mm Hg.
The only caveat to that is people who are over the age of 80 years, who have recently started treatment and in whom it might be difficult to get it down to those levels. And the best evidence we have is that we should target those to be below 150 systolic.
So 150 systolic, get below that over the age of 80 years. Less than 140 systolic over 90 for everybody else.
Now recently there was a publication, a big study from the United States called SPRINT, which targeted half the population in the study to a blood pressure below 120. And they showed a very significant reduction in mortality associated with cardiovascular disease, and even total mortality. So this has really fuelled the debate over whether we should be thinking about going even lower than 140 as our target for the treatment of hypertension.
Now before we jump to that conclusion we have to look at the SPRINT trial, and the kind of patients that went into that trial, and whether or not the result is generally applicable to the entire population or whether it really reflects a recommendation for a sub-population.
So the people in SPRINT had a high risk, they either had cardiovascular disease or chronic kidney disease, or they were over the age of 75 years. They did exclude people with diabetes and patients with a previous stroke, so that’s the first thing.
And secondly, many of the patients who went into the trial didn’t have particularly high blood pressure, so it wasn’t particularly difficult to get down to those targets.
So you can imagine if you see a patient in your typical clinical with a blood pressure of around 170, the idea, if they were 70 years old, trying to get them to below 120 – we all know that practically that would be quite challenging and technically quite difficult.
The other thing in SPRINT is that there was a significant increased risk of developing some side effects, hypotension, dizziness, renal impairment associated with the lower targets. So it didn’t come free – there was an offset in this trial.
So I think the data has stimulated debate, I don’t think it’s a definitive outcome. How do I interpret it in my practice? What I tend to do is I get everyone below 140. Then if I’m dealing with a patient who is quite high risk for cardiovascular disease – previously had a stroke, previously had a myocardial infarction, I will say to that patient ‘If you’re feeling okay at 135, we could try and go a bit lower. And it’s possible, if you tolerate that treatment, that you’ll get some added value from that.”
So I think what SPRINT has done is given justification to doctors to think about being more aggressive in patients who tolerate lower blood pressures than the conventional target, but we need to monitor them closely to make sure that they are tolerating this, and they are not running into any problems.
Should there be the same target blood pressure for everybody?
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