Guideline
The common guideline of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) generally recommends a target blood pressure <140/90 mmHg and an ambulatory 24-hour target blood pressure <130/80 mmHg. In addition, the guideline recommends:
- For older patients (> 80 years) there is a systolic target blood pressure of 140 - 150 mmHg with initial blood pressure values> 150 mmHg.
- For patients with diabetes mellitus, target diastolic blood pressure should be 80-85 mmHg.
- Patients with proteinuria have a target systolic blood pressure <130 mmHg.
The discussion of the optimal target blood pressure values has been rekindled due to the premature termination of the US SPRINT study (SPRINT = Systolic blood PRessure Intervention Trial) at the end of September 2015. Basically, two treatment principles are discussed:
- the maxim "the lower, the better"
- the principle of the "J-curve"
SPRINT trial
The aim of the SPRINT study was to determine if systolic blood pressure (SBP) below 120 mmHg is associated with a reduction in cardiovascular events compared to SBP below 140 mmHg:
- The multicenter, randomized study included 9361 patients> 50 years of age, SBP ≥ 130 mmHg and at least one of the following risk factors: cardiovascular disease, chronic renal failure (glomerular filtration rate [GFR] between 20 and 59 ml / min / 1.73 m2), 10-year Framingham risk score ≥ 15% or age> 75 years.
- Excluded from the study were patients with symptomatic heart failure or left ventricular pumping function below 35%, post-stroke conditions, diabetes mellitus, polycystic kidney disease, proteinuria ≥ 1 g / d and GFR below 20 ml / min / 1.73 m2.
- The study was discontinued on 11 September 2015 approximately 2 years before the planned end of the study by the study management, as the interim analysis showed a significant superiority of lower target blood pressure: 27% fewer deaths and 25% fewer cardiovascular events than in the intensified treatment group in the group with a target blood pressure below 140 mmHg. The results of the SPRINT study indicate that lower SBP targets (<120 mmHg) should be targeted for patients at increased cardiovascular risk. A recently published meta-analysis, which included approximately 50,000 patients, confirmed cardiovascular risk reduction for lower blood pressure readings.
It should be noted, however, that 2 large groups of patients with an increased cardiovascular risk in the SPRINT study were also excluded from the protocol:
- Patients with diabetes mellitus
- Patients after a stroke
Interestingly, the ACCORD trial in patients with diabetes demonstrated that SBP reduction below 120 mmHg had no positive effect on cardiovascular events. So far, studies on blood pressure targets in patients who have had a stroke have also failed to establish a clear target. When evaluating the results of the SPRINT study, it should also be considered that:
- 3 consecutive blood pressure measurements were performed with an automated, programmed meter, which almost excludes a potential "white coat effect"
- In contrast to current practice in Europe, mostly chlorothalidone was used as a diuretic instead of hydrochlorothiazide (HCT).
The treatment recommendations were based essentially on the treatment algorithm of the current European guidelines and a study-specific recommended algorithm, but were left to the investigators in their execution. In summary, the question arises as to whether the guideline's recommendations with a universal target are sufficient, or whether the history and co-morbidities should be weighted even more into a target value that is individually set for each patient.
SPRINT: In hypertensive high-risk patients, a systolic target below 120 mmHg reduces cardiovascular events by 25% and mortality by 27% compared to a target below 140 mmHg.
here is hypertension treatment algorithm (source from nmhs.net) :
