Weekly blog - Goal setting in hypertension

There was a fun argument about goal setting in hypertension targets:

I am a believer that you must always balance expected benefits (reductions in stroke, myocardial infarction, renal failure, CHF) against the potential harms (serious adverse drug effects).  Strict enforcement of arbitrary targets can lead to patient harm.  There is some evidence that the lower you treat the blood pressure, the lower certain events (i.e. stroke) with an increased risk of certain harms (i.e. renal failure, falls in the elderly).

Data on potential harm of over-treatment:

Hip fractures in the elderly:
http://www.ncbi.nlm.nih.gov/pubmed/23165923

"Hypertensive elderly persons who began receiving an antihypertensive drug had a 43% increased risk of having a hip fracture during the first 45 days following treatment initiation relative to the control periods (incidence rate ratio, 1.43; 95% CI, 1.19-1.72)."

Outcomes may be dependent on the diastolic blood pressure:
http://www.ncbi.nlm.nih.gov/pubmed/24026256

"The optimal BP in patients with CKD seems to be 130 to 159/70 to 89 mm Hg. It may not be advantageous to achieve ideal SBP at the expense of lower-than-ideal DBP in adults with CKD."

Why dual ACE/ARB combination really should not continue (there are several similar studies):
http://www.ncbi.nlm.nih.gov/pubmed/24206457

" There was no benefit with respect to mortality (hazard ratio for death, 1.04; 95% CI, 0.73 to 1.49; P=0.75) or cardiovascular events. Combination therapy increased the risk of hyperkalemia (6.3 events per 100 person-years, vs. 2.6 events per 100 person-years with monotherapy; P<0.001) and acute kidney injury (12.2 vs. 6.7 events per 100 person-years, P<0.001)."

Editorial here

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The JNC8 guidelines have abandoned the distinction between diabetics/renal failure patients and others with complicated hypertension:

"There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. "

The CHEP guidelines (2013) continue to make a distinction but use an even higher threshold for treatment in the general population.

1. Antihypertensive therapy should be prescribed for average diastolic blood pressures of 100 mmHg or higher (Grade A), or average systolic blood pressures of 160 mmHg or higher (Grade A) in patients without macrovascular target organ damage or other cardiovascular risk factors.
2. Antihypertensive therapy should be strongly considered if diastolic blood pressure readings average 90 mmHg or higher in the presence of macrovascular target organ damage or other independent cardiovascular risk factors (Grade A).
3. Antihypertensive therapy should be strongly considered if systolic blood pressure readings average 140 mmHg or higher in the presence of macrovascular target organ damage (Grade C for 140 mmHg to 160 mmHg; Grade A for higher than 160 mmHg).
4. Antihypertensive therapy should be considered in all patients meeting the above indications regardless of age (Grade B).  Caution should be exercised in elderly patients who are frail.

1. For patients with non-diabetic chronic kidney disease, target blood pressure is < 140/90 mmHg (Grade B).
2. Persons with diabetes mellitus should be treated to attain systolic blood pressures of less than 130 mmHg (Grade C) and diastolic blood pressures of less than 80 mmHg (Grade A). (These target blood pressure levels are the same as the blood pressure treatment thresholds.) 

Caution should be exercised in patients in whom a substantial fall in blood pressure is more likely or poorly tolerated (e.g. elderly patients and patients with autonomic neuropathy).