The Elusive Search for Optimal Blood Pressure Targets

BP treatment thresholds/targets determine when to initiate treatment and to what level BP should be reduced. The Seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) recommended a target of <140/90 for most patients and a target <130/80 mmHg for patients with diabetes or chronic kidney disease. Subsequently, meta-analyses, retrospective studies relating on-treatment BP to clinical outcomes and two large, randomized clinical trials (RCTs) have re-evaluated BP targets. In Action to Control Cardiovascular Risk in Diabetes (ACCORD), a systolic blood pressure (SBP) <120 mmHg was found not to be superior to SBP <140 mmHg in diabetics. In SPRINT (Systolic Blood Pressure Intervention Trial) which studied a different population, the lower target resulted in a 25% cardiovascular event reduction. Despite unresolved issues, certain recommendations can be made with confidence. SBP >160 mmHg should, with rare exceptions, be treated. The historical threshold/target of 140/90 mmHg remains reasonable in most patients in identifying “treatable” risk, i.e., risk high enough to justify treatment and for which available treatment is effective enough to result in significant endpoint reduction. Above 140/90 mmHg, most low-to-moderate risk people should be treated and this target is also appropriate for the majority of high-risk individuals with diabetes, CKD, and/or CAD. The advisability of initiating or intensifying treatment with BPs in the 130s remains equivocal. The next steps in the search for more precise BP targets should include (1) standardization of BP measurement techniques and (2) well-designed RCTs evaluating a treatment target of SBP <130 in carefully categorized patient populations.