What is goal blood pressure in the treatment of hypertension?
- Johannes FE Mann, MD
Johannes FE Mann, MD
- Professor of Medicine
- Friedrich Alexander University of Erlangen-Nürnberg
- International Scholar, Population Health Research Institute, McMaster University, Canada
- Karl F Hilgers, MD
Karl F Hilgers, MD
- Professor of Internal Medicine and Hypertension Research
- Friedrich-Alexander University, Erlangen-Nuremberg
- Vice Chair, Department of Nephrology and Hypertension
- Erlangen University Hospital
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
An increasing number of trials have provided evidence that antihypertensive therapy to attain blood pressure control provides some degree of cardiovascular protection. However, the optimal level of control may vary across certain patient populations [1,2]. In general, the benefits of increasingly intensive therapy must be weighed against the potentially increased incidence of serious side effects associated with such a regimen.
The rationale for specific goal blood pressure levels in the general hypertensive population, the possible risks of excessive blood pressure lowering, and our approach to setting blood pressure goals will be reviewed here.
Separate issues related to the management of hypertension are presented elsewhere, including:
●Treatment of hypertension in patients with diabetes (see "Treatment of hypertension in patients with diabetes mellitus")
●Treatment of hypertension in patients with nondiabetic chronic kidney disease (CKD) (see "Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults")
- Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013; 31:1281.
- James PA, Oparil S, Carter BL, et al. 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). JAMA 2014; 311:507.
- Bakris GL. The Implications of Blood Pressure Measurement Methods on Treatment Targets for Blood Pressure. Circulation 2016; 134:904.
- Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens 2014; 32:3.
- Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation 2007; 115:2761.
- Hackam DG, Quinn RR, Ravani P, et al. The 2013 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2013; 29:528.
- Franklin SS, Gokhale SS, Chow VH, et al. Does low diastolic blood pressure contribute to the risk of recurrent hypertensive cardiovascular disease events? The Framingham Heart Study. Hypertension 2015; 65:299.
- Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560.
- Pastor-Barriuso R, Banegas JR, Damián J, et al. Systolic blood pressure, diastolic blood pressure, and pulse pressure: an evaluation of their joint effect on mortality. Ann Intern Med 2003; 139:731.
- Blacher J, Staessen JA, Girerd X, et al. Pulse pressure not mean pressure determines cardiovascular risk in older hypertensive patients. Arch Intern Med 2000; 160:1085.
- Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension 1995; 25:305.
- Kannel WB. Elevated systolic blood pressure as a cardiovascular risk factor. Am J Cardiol 2000; 85:251.
- Staessen JA, Gasowski J, Wang JG, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000; 355:865.
- Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360:1903.
- Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 2016; 387:957.
- Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels - updated overview and meta-analyses of randomized trials. J Hypertens 2016; 34:613.
- Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet 2016; 387:435.
- Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA 1967; 202:1028.
- Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA 1970; 213:1143.
- Hebert PR, Moser M, Mayer J, et al. Recent evidence on drug therapy of mild to moderate hypertension and decreased risk of coronary heart disease. Arch Intern Med 1993; 153:578.
- MRC trial of treatment of mild hypertension: principal results. Medical Research Council Working Party. Br Med J (Clin Res Ed) 1985; 291:97.
- Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. Hypertension Detection and Follow-up Program Cooperative Group. JAMA 1979; 242:2562.
- The effect of treatment on mortality in "mild" hypertension: results of the hypertension detection and follow-up program. N Engl J Med 1982; 307:976.
- Liu L, Zhang Y, Liu G, et al. The Felodipine Event Reduction (FEVER) Study: a randomized long-term placebo-controlled trial in Chinese hypertensive patients. J Hypertens 2005; 23:2157.
- Lonn EM, Bosch J, López-Jaramillo P, et al. Blood-Pressure Lowering in Intermediate-Risk Persons without Cardiovascular Disease. N Engl J Med 2016; 374:2009.
- Blood Pressure Lowering Treatment Trialists' Collaboration, Sundström J, Arima H, et al. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet 2014; 384:591.
- Emdin CA, Rahimi K, Neal B, et al. Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis. JAMA 2015; 313:603.
- SPRINT Research Group, Wright JT Jr, Williamson JD, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373:2103.
- Bress AP, Tanner RM, Hess R, et al. Generalizability of SPRINT Results to the U.S. Adult Population. J Am Coll Cardiol 2016; 67:463.
- Oliva RV, Bakris GL. Management of hypertension in the elderly population. J Gerontol A Biol Sci Med Sci 2012; 67:1343.
- Boutitie F, Gueyffier F, Pocock S, et al. J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data. Ann Intern Med 2002; 136:438.
- Staessen J, Bulpitt C, Clement D, et al. Relation between mortality and treated blood pressure in elderly patients with hypertension: report of the European Working Party on High Blood Pressure in the Elderly. BMJ 1989; 298:1552.
- Kaplan NM. What is goal blood pressure for the treatment of hypertension? Arch Intern Med 2001; 161:1480.
- Farnett L, Mulrow CD, Linn WD, et al. The J-curve phenomenon and the treatment of hypertension. Is there a point beyond which pressure reduction is dangerous? JAMA 1991; 265:489.
- Vidal-Petiot E, Ford I, Greenlaw N, et al. Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease: an international cohort study. Lancet 2016.
- D'Agostino RB, Belanger AJ, Kannel WB, Cruickshank JM. Relation of low diastolic blood pressure to coronary heart disease death in presence of myocardial infarction: the Framingham Study. BMJ 1991; 303:385.
- Berl T, Hunsicker LG, Lewis JB, et al. Impact of achieved blood pressure on cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial. J Am Soc Nephrol 2005; 16:2170.
- Messerli FH, Mancia G, Conti CR, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med 2006; 144:884.
- Dorresteijn JA, van der Graaf Y, Spiering W, et al. Relation between blood pressure and vascular events and mortality in patients with manifest vascular disease: J-curve revisited. Hypertension 2012; 59:14.
- Sleight P, Redon J, Verdecchia P, et al. Prognostic value of blood pressure in patients with high vascular risk in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial study. J Hypertens 2009; 27:1360.
- Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010; 304:61.
- Vokó Z, Bots ML, Hofman A, et al. J-shaped relation between blood pressure and stroke in treated hypertensives. Hypertension 1999; 34:1181.
- Somes GW, Pahor M, Shorr RI, et al. The role of diastolic blood pressure when treating isolated systolic hypertension. Arch Intern Med 1999; 159:2004.
- Shorr RI, Somes GW. Can Diastolic Blood Pressure be Excessively Lowered in the Treatment of Isolated Systolic Hypertension? J Clin Hypertens (Greenwich) 2000; 2:134.
- Flack JM, Neaton J, Grimm R Jr, et al. Blood pressure and mortality among men with prior myocardial infarction. Multiple Risk Factor Intervention Trial Research Group. Circulation 1995; 92:2437.
- Lazarus JM, Bourgoignie JJ, Buckalew VM, et al. Achievement and safety of a low blood pressure goal in chronic renal disease. The Modification of Diet in Renal Disease Study Group. Hypertension 1997; 29:641.
- Bulpitt CJ, Palmer AJ, Fletcher AE, et al. Optimal blood pressure control in treated hypertensive patients. Report from the Department of Health Hypertension Care Computing Project (DHCCP). Circulation 1994; 90:225.
- Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA 1991; 265:3255.
- Pepine CJ, Handberg EM, Cooper-DeHoff RM, et al. A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial. JAMA 2003; 290:2805.
- Wang JG, Staessen JA, Franklin SS, et al. Systolic and diastolic blood pressure lowering as determinants of cardiovascular outcome. Hypertension 2005; 45:907.
- Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998; 351:1755.
- Kaplan N. J-curve not burned off by HOT study. Hypertension Optimal Treatment. Lancet 1998; 351:1748.
- Zanchetti A, Hansson L, Clement D, et al. Benefits and risks of more intensive blood pressure lowering in hypertensive patients of the HOT study with different risk profiles: does a J-shaped curve exist in smokers? J Hypertens 2003; 21:797.
- Lund-Johansen P. Intensive blood pressure treatment: beneficial for all but the smoking hypertensives? J Hypertens 2003; 21:697.
- OUR APPROACH TO GOAL BLOOD PRESSURE
- NATURAL HISTORY OF BLOOD PRESSURE AND RELATION TO CARDIOVASCULAR DISEASE
- EVIDENCE OF BENEFIT FROM TREATING HYPERTENSION
- Systolic and diastolic hypertension
- - Benefit according to severity of hypertension
- Benefit in those with severe hypertension
- Benefit in those with moderate hypertension
- Benefit in those with mild hypertension
- - Benefit according to overall cardiovascular risk
- Isolated systolic hypertension
- J-SHAPED CURVE AND QUESTION OF HARM FROM LOWER BLOOD PRESSURE
- J-shaped diastolic curve
- J-shaped systolic curve
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS