Should Patients With Cardiovascular Risk Factors Receive Intensive Treatment of Hypertension to <120/80 mm Hg Target?
2016; Lippincott Williams & Wilkins; Volume: 134; Issue: 18 Linguagem: Inglês
10.1161/circulationaha.116.023264
ISSN1524-4539
Autores Tópico(s)Heart Rate Variability and Autonomic Control
ResumoHomeCirculationVol. 134, No. 18Should Patients With Cardiovascular Risk Factors Receive Intensive Treatment of Hypertension to <120/80 mm Hg Target? Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBShould Patients With Cardiovascular Risk Factors Receive Intensive Treatment of Hypertension to 115 mm Hg and diastolic BP >75 mm Hg. However, it remains unclear whether pharmacologic BP lowering to these levels reduces cardiovascular (CV) events and is safe.Observational analyses raised concerns about aggressive BP lowering to levels <120/80 mm Hg, suggesting the existence of a J-curve phenomenon with increased risk especially for coronary events. However, such analyses are potentially confounded. More reliable data are provided by randomized trials.Most BP-lowering trials have evaluated patients with high pretreatment BP and have rarely achieved average systolic BP <130 to 140 mm Hg, except in patients with high-risk CV disease, such as recent myocardial infarction (MI) or heart failure (HF) or those with chronic kidney disease. Three recent trials have specifically compared intensive systolic BP lowering to targets of <120 to 130 mm Hg versus traditional guideline recommended targets of generally <140 mm Hg,1–3 while the older HOT trial (Hypertension Optimal Treatment) randomized patients to diastolic BP targets of ≤90, ≤85, or ≤80 mm Hg.4 These trials differ significantly in their design, patients' characteristics and CV risk, BP regimens, duration of treatment, primary outcomes, BP measurement techniques, and results. The ACCORD trial (Action to Control Cardiovascular Risk in Diabetes) randomized 4733 patients with diabetes (mean 63 years of age, 34% with a previous CV event, BP 139/76 mm Hg) to intensive therapy to a systolic BP target <120 mm Hg or to a standard target <140 mm Hg.1 Intensive therapy lowered BP by 14.2/6.1 mm Hg but did not reduce the primary outcome of CV death, MI, stroke, or secondary outcomes, including HF and overall coronary events. A significant reduction in stroke occurred, although the number of strokes was low. The SPS3 trial (Secondary Prevention of Small Subcortical Strokes) randomized 3020 patients (mean 63 years of age, BP 143/79 mm Hg) with a recent small subcortical stroke to a systolic BP target <130 mm Hg or between 130 and 149 mm Hg.2 The difference in systolic BP was 11 mm Hg, but no significant reduction occurred in the primary outcome, recurrent stroke, or the secondary outcome, the composite of MI and vascular death. ACCORD and SPS3 may be underpowered, although the number of major CV events in ACCORD (including HF) is similar to that in SPRINT (Systolic Blood Pressure Intervention Trial).3 The only trial that showed benefit for intensive systolic BP lowering 143.5 mm Hg, mean of 154.1 mm Hg) despite a more modest 6/3 mm Hg BP lowering, with no benefit in those with lower entry BP. These benefits were safely enhanced by simultaneous administration of a statin (40% relative risk reduction). These findings support antihypertensive therapy in mild uncomplicated hypertension with initiation of therapy at systolic BP >140 mm Hg. Specific targets of therapy were not tested in HOPE-3. However, results of this subgroup analysis suggest that aggressive targets in this intermediate risk population are not justified. Treatment was extremely safe and follow-up visits were infrequent and streamlined so that the HOPE-3 approach is widely applicable.In summary, aggressive systolic BP targets may be used in selected, high-risk individuals treated in specialized settings using standardized automated BP measurements and careful and frequent monitoring, although further confirmation of the SPRINT targets would make such recommendations more persuasive. Limited data are available for diastolic BP targets <80 mm Hg, except possibly in diabetics (limited data from HOT). The simple, less aggressive treatment approach used in HOPE-3 appears reasonable for intermediate-risk persons with uncomplicated grade 1 hypertension, should be complemented by statin therapy, and can be readily incorporated into clinical practice in most settings.Sources of FundingThe HOPE-3 trial was funded by the Canadian Institutes of Health Research and Astra Zeneca.DisclosuresNone.FootnotesThis is part II of a 2-part article. Part I appears on p 1308.Circulation is available at http://circ.ahajournals.org.Correspondence to: Eva Lonn, MD, MSc, Population Health Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada. E-mail [email protected]References1. The ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus.N Engl J Med. 2010; 362: 1575–1585.CrossrefMedlineGoogle Scholar2. The SPS3 Study Group. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial.Lancet. 2013; 382:507–515.CrossrefMedlineGoogle Scholar3. Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM, Rahman M, Oparil S, Lewis CE, Kimmel PL, Johnson KC, Goff DC, Fine LJ, Cutler JA, Cushman WC, Cheung AK, Ambrosius WT; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control.N Engl J Med. 2015; 373:2103–2116. doi: 10.1056/NEJMoa1511939.CrossrefMedlineGoogle Scholar4. Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S, Ménard J, Rahn KH, Wedel H, Westerling S. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group.Lancet. 1998; 351:1755–1762.CrossrefMedlineGoogle Scholar5. Lonn EM, Bosch J, López-Jaramillo P, Zhu J, Liu L, Pais P, Diaz R, Xavier D, Sliwa K, Dans A, Avezum A, Piegas LS, Keltai K, Keltai M, Chazova I, Peters RJ, Held C, Yusoff K, Lewis BS, Jansky P, Parkhomenko A, Khunti K, Toff WD, Reid CM, Varigos J, Leiter LA, Molina DI, McKelvie R, Pogue J, Wilkinson J, Jung H, Dagenais G, Yusuf S; HOPE-3 investigators. Blood-pressure lowering in intermediate-risk persons without cardiovascular disease.N Engl J Med. 2016; 374:2009–2020. doi: 10.1056/NEJMoa1600175.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Manu P, Rogozea L, Ivanescu-Lint A and Dan G (2022) Pharmacological Management of Primary Arterial Hypertension: A Century of Expert Opinions in Cecil Textbook of Medicine, American Journal of Therapeutics, 10.1097/MJT.0000000000001505, 29:3, (e287-e297) de la Torre J Hemodynamic Instability in Heart Failure Intensifies Age-Dependent Cognitive Decline, Journal of Alzheimer's Disease, 10.3233/JAD-200296, 76:1, (63-84) Leung A and Padwal R (2018) Blood Pressure–Lowering Targets in Patients With Diabetes Mellitus, Canadian Journal of Cardiology, 10.1016/j.cjca.2017.10.024, 34:5, (644-652), Online publication date: 1-May-2018. Streit S, Gussekloo J, Burman R, Collins C, Kitanovska B, Gintere S, Gómez Bravo R, Hoffmann K, Iftode C, Johansen K, Kerse N, Koskela T, Peštić S, Kurpas D, Mallen C, Maisonneuve H, Merlo C, Mueller Y, Muth C, Ornelas R, Šter M, Petrazzuoli F, Rosemann T, Sattler M, Švadlenková Z, Tatsioni A, Thulesius H, Tkachenko V, Torzsa P, Tsopra R, Tuz C, Verschoor M, Viegas R, Vinker S, de Waal M, Zeller A, Rodondi N and Poortvliet R (2018) Burden of cardiovascular disease across 29 countries and GPs' decision to treat hypertension in oldest-old, Scandinavian Journal of Primary Health Care, 10.1080/02813432.2018.1426142, 36:1, (89-98), Online publication date: 2-Jan-2018. Wang S, Khera R, Das S, Vigen R, Wang T, Luo X, Lu R, Zhan X, Xiao G, Vongpatanasin W and Xie Y (2018) Usefulness of a Simple Algorithm to Identify Hypertensive Patients Who Benefit from Intensive Blood Pressure Lowering, The American Journal of Cardiology, 10.1016/j.amjcard.2018.03.361, 122:2, (248-254), Online publication date: 1-Jul-2018. Reamy B, Williams P and Kuckel D (2018) Prevention of Cardiovascular Disease, Primary Care: Clinics in Office Practice, 10.1016/j.pop.2017.11.003, 45:1, (25-44), Online publication date: 1-Mar-2018. Chrysant S (2018) Aggressive systolic blood pressure control in older subjects: benefits and risks, Postgraduate Medicine, 10.1080/00325481.2018.1433434, 130:2, (159-165), Online publication date: 17-Feb-2018. Brewster L, van Montfrans G and Seedat Y (2018) Antihypertensive Drug Therapy in Patients of African and South Asian Ethnicity: A Systematic Review Ethnic Diversities, Hypertension and Global Cardiovascular Risk, 10.1007/978-3-319-93148-7_20, (243-269), . Buckley L, Dixon D, Wohlford G, Wijesinghe D, Baker W and Van Tassell B (2017) Intensive Versus Standard Blood Pressure Control in SPRINT-Eligible Participants of ACCORD-BP, Diabetes Care, 10.2337/dc17-1366, 40:12, (1733-1738), Online publication date: 1-Dec-2017. Elias M, Torres R and Davey A (2017) Intensive Blood Pressure Control Improves Cognitive Performance: Pushing the Envelope cum Judicia, American Journal of Hypertension, 10.1093/ajh/hpx043, 30:6, (556-558), Online publication date: 1-Jun-2017. Katsiki N, Purrello F, Tsioufis C and Mikhailidis D (2017) Cardiovascular disease prevention strategies for type 2 diabetes mellitus, Expert Opinion on Pharmacotherapy, 10.1080/14656566.2017.1351946, 18:12, (1243-1260), Online publication date: 13-Aug-2017. Arguedas J, Leiva V and Wright J (2020) Blood pressure targets in adults with hypertension, Cochrane Database of Systematic Reviews, 10.1002/14651858.CD004349.pub3, 2020:12 November 1, 2016Vol 134, Issue 18 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.116.023264PMID: 27619924 Originally publishedSeptember 12, 2016 Keywordshigh blood pressureriskantihypertensive agenthypertensiontreatmentPDF download Advertisement SubjectsHigh Blood PressureHypertensionVascular Disease
Referência(s)