Evidence Supporting the Blood Pressure Treatment Goal of Less Than 130/80 mm Hg

The debate over the optimal blood pressure treatment target of less than 130/80 mmHg

OBJECTIVES

The objective of this study was to analyze the controversy regarding the optimal blood pressure (BP) target of <130/80 mmHg as proposed by the 2017 American College of Cardiology/American Heart Association (ACC/AHA) across all age groups. Hypertension is a major risk factor for cardiovascular disease (CVD), stroke, and chronic kidney disease (CKD), and its optimal control is associated with lessening or preventing these complications. A recent study has argued that this BP level is universally accepted as an optimal and safe BP level. However, this argument is not accepted by other investigators, arguing that higher BP levels are as effective and safe.

METHODS

In order to investigate the current status of this level of BP control, a Medline search of the English literature was conducted between 2017 and February 2022, and 25 pertinent papers were selected.

RESULTS

The analysis of data from these studies indicates that these BP are effective in lowering the BP and preventing cardiovascular disease, heart failure, and chronic kidney disease, and they are indeed universally accepted.

CONCLUSION

Based on the current evidence, the current proposed by the 2017 ACC/AHA treatment guidelines are effective in lowering the BP and decreasing its cardiovascular complications and should followed, till perhaps, new data come out to the contrary.

Platelet Function Is Associated With Dementia Risk in the Framingham Heart Study

Background Vascular function is compromised in Alzheimer disease (AD) years before amyloid and tau pathology are detected and a substantial body of work shows abnormal platelet activation states in patients with AD. The aim of our study was to investigate whether platelet function in middle age is independently associated with future risk of AD. Methods and Results We examined associations of baseline platelet function with incident dementia risk in the community-based FHS (Framingham Heart Study) longitudinal cohorts. The association between platelet function and risk of dementia was evaluated using the cumulative incidence function and inverse probability weighted Cox proportional cause-specific hazards regression models, with adjustment for demographic and clinical covariates. Platelet aggregation response was measured by light transmission aggregometry. The final study sample included 1847 FHS participants (average age, 53.0 years; 57.5% women). During follow-up (median, 20.5 years), we observed 154 cases of incident dementia, of which 121 were AD cases. Results from weighted models indicated that platelet aggregation response to adenosine diphosphate 1.0 µmol/L was independently and positively associated with dementia risk, and it was preceded in importance only by age and hypertension. Sensitivity analyses showed associations with the same directionality for participants defined as adenosine diphosphate hyper-responders, as well as the platelet response to 0.1 µmol/L epinephrine. Conclusions Our study shows individuals free of antiplatelet therapy with a higher platelet response are at higher risk of dementia in late life during a 20-year follow-up, reinforcing the role of platelet function in AD risk. This suggests that platelet phenotypes may be associated with the rate of dementia and potentially have prognostic value.

Implementation of the 2017 American College of Cardiology/American Heart Association Guidelines on Hypertension in Clinical Practice

Background: The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on hypertension recommend a threshold blood pressure (BP) of ≥130/80 mmHg for diagnosis of hypertension and treating hypertension to a goal BP of <130/80 mmHg. For this study, we assessed the rate of compliance to the 2017 ACC/AHA hypertension guidelines by internal medicine residents and cardiology fellows in clinics affiliated with a teaching hospital in New York, New York.

Methods: We conducted a retrospective medical records review for patients who had a clinical encounter at the internal medicine resident and cardiology fellow clinics from January to February 2019. To distinguish from adherence with prior guidelines, patients with BP of 130-139/80-89 mmHg (unless age ≥60 years and systolic blood pressure [SBP] 140-149 mmHg without chronic kidney disease or diabetes) were included. The primary outcome was accurate assessment of uncontrolled BP in accordance with the 2017 ACC/AHA guidelines.

Results: Included in the analysis were 435 patients from the internal medicine resident clinic and 127 patients from the cardiology fellow clinic. Accurate assessment of uncontrolled BP was higher in the cardiology fellow clinic compared to the internal medicine resident clinic (29.1% vs 10.3%, P<0.001), even after adjusting for baseline characteristics differences between the 2 clinics. Multivariate regression analysis revealed that the type of clinic (internal medicine, odds ratio [OR] 0.27, 95% CI 0.16-0.47; P<0.001), established diagnosis of hypertension (OR 2.06, 95% CI 1.06-3.99; P<0.001), and SBP (OR 1.16 per mmHg, 95% CI 1.11-1.22; P=0.031) were independently associated with the primary outcome.

Conclusion: Cardiology fellows were better at identifying hypertension diagnosis thresholds and BP treatment goals in accordance with 2017 ACC/AHA guidelines compared to internal medicine residents.

Guideline-Driven Management of Hypertension: An Evidence-Based Update

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

Resistant Hypertension Management: Comparison of the 2017 American and 2018 European High Blood Pressure Guidelines

PURPOSE OF REVIEW

To compare European and American guidelines for the diagnosis, evaluation, and management of resistant hypertension.

RECENT FINDINGS

Resistant hypertension is defined as high blood pressure that remains above goal with the use of 3 or more antihypertensive agents, commonly a renin-angiotensin blocker (either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker), a long-acting calcium channel blocker, and thiazide or thiazide-like diuretic. Resistant hypertension is common, with a recent analysis indicating that it affects approximately 17-19% of adult Americans with hypertension. Pseudocauses of apparent resistant hypertension, including inaccurate blood pressure measurement, white coat effect, undertreatment, and poor medication adherence, must be excluded in order to confirm true resistant hypertension. Evaluation of resistant hypertension requires identifying and treating secondary causes of hypertension, including obstructive sleep apnea, primary aldosteronism, and renal artery stenosis. Treatment of resistant hypertension includes a combined use of lifestyle modification and prescription of effective multiple-drug combinations. Preferential use of a long-acting thiazide-like diuretic, either chlorthalidone or indapamide, and a mineralocorticoid receptor blocker, most commonly spironolactone, is recommended if needed to achieve blood pressure control. Aside for small exceptions, European and American guidelines agree in terms of recommendations for diagnosing, evaluating, and treating resistant hypertension.