How Low To Go: The Continuing Controversy on BP Targets

VA Research Supports More Flexible Goals in Older Patients

By Brenda L. Mooney

PHILADELPHIA — After the release of the SPRINT research in 2015, the question about treating hypertension in older adults appeared to be, “How low can you go?”

Now, based on critical research from the Portland, OR, VA Healthcare System, two major physicians group have rejected that mentality in recent guidelines. Those documents suggested that systolic blood pressure below 150 mm Hg is sufficient for most patients older than 60 to reduce their risk of mortality, stroke and cardiac events.

The evidence-based clinical practice guideline on the appropriate systolic blood pressure target for adults 60 years old and older with hypertension was developed jointly by the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) and published in Annals of Internal Medicine.1

The new document has provoked controversy because many other guidelines recommend that all adults, at least to age 80, seek to lower systolic blood pressure to below 140 mm Hg. In addition, the high-profile 2015 SPRINT study urged that the target be even lower.

Background information in the guidelines article, authored by a team from the American College of Physicians and University of Pennsylvania Health System, noted that about 65% of those older than 60 have hypertension in the United States, compared to an overall adult rate of about 29%.

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Comments (2)

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  1. Mark McConnell, M.D. says:

    Will VA Performance Measures catch up with evidence and allow home BP readings to “count” when assessing control? I suspect there is a lot of potential over-treatment caused by chasing only “in office” readings.

  2. William C. Cushman, MD says:

    I was one of the lead investigators for ACCORD and SPRINT and am the principal investigator overseeing the VA clinical center networks for those trials. I was also the VA Champion for the 2014 VA/DoD Hypertension guidelines and on the 2014 JNC 8 Hypertension Guideline panel – in both of those guidelines we also recommended the same /=50 years). The landmark VA Cooperative Hypertension Study of the 1960s proved the treatment of (diastolic) hypertension is beneficial, SHEP in 1991 proved treating isolated systolic hypertension (>/=160 mm Hg) is beneficial and both changed subsequent guidelines as single trials. I also believe the accompanying meta-analysis supports treating to lower levels despite including many trials with much higher BP goals. The 2016 Canadian and Australian hypertension guidelines have already recommended lower goals in certain high-risk groups and a guideline sponsored by ACC, AHA, ASH, and many other organizations is due out later this year. Hopefully, VA/DoD guidelines will also be updated subsequently as well. I would encourage clinicians to now consider treating patients at high risk for cardiovascular disease (at least those who are similar to SPRINT participants) to systolic BP levels well below 150 mm Hg.

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