Reduction of diastolic blood pressure: Should hypertension guidelines include a lower threshold target?

Blood pressure goals: A moving target

Clinical guidelines on hypertension have evolved over the past several decades. Each recommends varying blood pressure (BP) cut-offs which define hypertension, determine the thresholds to initiate pharmacotherapy, and guide treatment targets. In addition, different techniques of measuring BP in clinical trials may further contribute to the discrepancies in the achieved BP targets. Physicians find it difficult to navigate through different recommendations for hypertension management based on studies among different age groups and patients with a variety of co-morbidities and target organ involvement. In 2003, JNC 7 recommended a BP goal of < 140/90 mmHg in the general population and < 130/80 mmHg in those with diabetes mellitus or renal disease. JNC 8 re-set the BP target at < 140/90 mmHg for all adults under the age of 60 regardless of co-morbidities, and an even higher target of < 150/90 mmHg for those 60 years or older without diabetes or chronic kidney disease. The more recent results of the Systolic BP Intervention Trial (SPRINT) have a significant influence on the 2017 American College of Cardiology (ACC) and American Heart Association (AHA) guideline which redefines hypertension as BP ≥ 130/80 mmHg. It emphasizes individualized cardiovascular risk assessment and recommends a more aggressive BP target of < 130/80 mmHg and a treatment threshold based on the age, co-morbidities, and cardiovascular risk. The 2017 ACC/AHA guideline also advocates proper BP measurement and provides the estimates of corresponding BP values for clinic, home, and ambulatory BP monitoring measurements. A higher prevalence of hypertension is expected based on the ACC/AHA 2017 guideline. Its implementation may potentially lead to better BP control through enhanced awareness, improved adherence, and more timely initiation and intensification of pharmacologic therapy. Although there is no one-size-fits-all BP target, the ACC/AHA 2017 guideline is simple, inclusive and practical. Nonetheless, more studies are warranted to help further individualize BP goals for elderly patients and those with certain co-morbidities or multiple cardiovascular risk factors.