Blood Pressure Targets  2017.Still Struggling for the Right Answer

Magdy El-Masry

Prof. of Cardiology

Tanta University

ObjectivesDiscuss what’s old but still important

Know What's New: Hypertension 2017

Blood Pressure TargetsWhat Do the New Guidelines Say ?

Achieving BP goals in hypertensive patients

The most clinically relevant

measure of BP control.

Guidelines For Hypertension 2011-2015

A Flood of Hypertension Guidelines

Plethora of HTN guidelines

Oct 2011Oct 2015

Jun 2013

US Hypertension Guideline Mania

Nov 2013

2015 20102012

Dec 2013Dec 2013

2014

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.”

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

What target BP goals are recommended in

the new guideline?

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

2015 CHEP

Blood pressure targets recommendations in CKD

Class/Level of EvidenceConditionBP Goal (mmHg)

IIa/BAge >80 years< 150/90

I/AIIa/CIIa/B

CADACSHF

< 140/90

IIb/CIIb/C

CADPost-MI, stroke, TIA

CAD, PAD, AAA

< 130/80

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).

1

1977

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1980

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1984

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1988

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1993

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1997

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2003

8

2014

The Joint National Committee (JNC )

The controversial JNC 8 relaxed BP goals from

140/90 to 150/90

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

The recent publication of the SPRINT has again opened the debate on optimal BP targets.

Does SPRINT change our approach to BP targets?

SPRINT vs. ACCORDWhich Target Will Win in Diabetes?

Outcomes Data from SPRINT and the ACCORD Trial and Combined Data from Both Trials.

In both the Systolic Blood Pressure Intervention Trial (SPRINT) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the systolic blood-pressure target in the intensive-treatment group was less than 120 mm Hg, and the target in the standard-treatment group was less than 140 mm Hg.

Know What's New: Hypertension 2017

The early release of SPRINT results has not been accompanied by a similar change in treatment guidelines. The exception is the Canadian Hypertension

Education Program (CHEP) guidelines, which are updated annually

The state of CHEP guidelinespre-SPRINT post-SPRINT

3 Clinical or sub-clinical CVD,CKD (non-diabetic nephropathy, proteinuria <1 g/d, or eGFR20-59 mL/min/1.73m2),Estimated 10-year global cardiovascular risk >15%.Age ≥ 75 years.

1 Elderly defined as > 80 years age, non-diabetic, with no CKD

Hypertension in 2017—What Is the Right Target?

Updated Hypertension Guidelines Released by ACP, AAFP

(published online January 17 in the Annals of Internal Medicine.)

Recommendation 1: ACP and AAFP recommend that clinicians initiate

treatment in adults aged 60 years or older with

systolic blood pressure persistently at or above 150

mm Hg to achieve a target systolic blood pressure

of less than 150 mm Hg to reduce the risk for

mortality, stroke, and cardiac events.(Grade : strong recommendation, high-quality evidence).

Recommendation 2:ACP and AAFP recommend that clinicians

consider initiating or intensifying pharmacologic

treatment in adults aged 60 years or older with a

history of stroke or transient ischemic attack to

achieve a target systolic blood pressure of less

than 140 mm Hg to reduce the risk for recurrent

stroke. (Grade : weak recommendation, moderate-quality evidence).

Recommendation 3: ACP and AAFP recommend that clinicians

consider initiating or intensifying pharmacologic

treatment in some adults aged 60 years or older at

high cardiovascular risk , based on individualized

assessment, to achieve a target systolic blood

pressure of less than 140 mm Hg to reduce the

risk for stroke or cardiac events. (Grade : weak recommendation, low quality evidene).

Clinicians should individually assess cardiovascular risk for patients.Generally , increased cardiovascular risk includes persons with known vascular disease,

most patients with diabetes , older persons with chronic kidney disease with eGFR less than 45 mL/min/per 1.73 m2, those with metabolic syndrome (abdominal obesity, hypertension, diabetes, and dyslipidemia),and older persons.