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The relative reduction in stroke events was slightly larger for studies that achieved a target SBP of mm Hg or greater RR, 0. These studies had marked clinical differences and significant statistical heterogeneity, which should temper confidence in the pooled results. Use of antihypertensive agents varied widely across studies: 7 used ACEIs or ARBs, 5 used calcium-channel blockers, and 6 used thiazide-like diuretics.

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Among patients with a history of stroke or transient ischemic attack TIA , moderate-quality evidence showed that treating to an SBP of to mm Hg reduced stroke recurrence RR, 0. Heterogeneity for this analysis was low. Low-quality evidence showed similar effects across different age groups 12—14 , 16 , 18—20 , 22 , 24 , 26 , 28 , A subgroup analysis of SPRINT Systolic Blood Pressure Intervention Trial that was not included in the evidence review showed that patients aged 75 years or older had lower all-cause mortality and nonstatistically significantly lower cardiovascular mortality, morbidity, and incidence of stroke with treatment to SBP targets less than mm Hg compared with SBP targets less than mm Hg No trials assessed the effect of comorbidity on the benefits of more aggressive BP treatment.

Low-quality evidence from subgroup analyses showed greater absolute benefit from more intensive BP treatment in patients with high cardiovascular risk 22 , 29— However, patients with a high comorbidity burden were probably not included in the overall group of studies 8. Of the 21 trials included in the review, 14 excluded patients with heart failure, 11 excluded those with recent cardiovascular events, 17 excluded those with abnormal renal function, 12 excluded those with cancer or other life-limiting illness, 15 had criteria that would implicitly or explicitly exclude those with dementia or diminished functional status, and 7 excluded either all diabetic patients or those who required insulin.

Although findings from ACCORD Action to Control Cardiovascular Risk in Diabetes , which limited enrollment to patients with type 2 diabetes, found no reduction in mortality or major cardiovascular events with more intensive treatment, a subgroup analysis of 7 studies 12 , 14 , 18—20 , 28 , 29 in diabetic patients suggested that they were at least as likely to benefit from BP-lowering treatment. This is probably related to the higher frequency of cardiovascular events seen in these patients.

Evidence was insufficient to determine the benefit of treating diastolic hypertension in the absence of systolic hypertension. Studies showed mixed findings for withdrawal due to adverse events.


Low-quality evidence showed an increased risk for syncope associated with treatment to lower BP targets achieved SBP range, Low-quality evidence showed no difference in renal outcomes including end-stage renal disease for treatment to higher versus lower BP targets 13 , 15 , 16 , 18 , 20 , 22—25 , 28 , 29 , 32— Moderate-quality evidence showed no differences between treatment to higher versus lower BP targets in the degree of cognitive decline or dementia 18 , 27 , 35—39 , fractures 40 , 41 , or quality of life 17 , 42— Low-quality evidence showed no difference for treatment to higher versus lower BP targets on functional status 42 or the risk for falls 23 , A subgroup analysis of SPRINT showed a nonstatistically significant increase in the rate of serious adverse events, hypotension, syncope, electrolyte abnormalities, or acute kidney injury in patients aged 75 years or older who were treated to SBP targets less than mm Hg versus SBP targets less than mm Hg Although electrolyte disturbances are a common adverse effect of hypertension treatment in clinical practice, data were not presented on these abnormalities in the evidence review.

Drugs to treat hypertension have well-known adverse effects, including hypokalemia, hyperkalemia, hyponatremia, hypotension, dizziness, headache, edema, erectile dysfunction, and cough. Low-quality evidence showed no difference in adverse events, including unsteadiness, dizziness, and renal failure, in patients younger or older than 75 years 13 , 23 , No trials assessed the effect of comorbid conditions on harms.

The Figure summarizes the recommendations and clinical considerations. Moderate-quality evidence showed a possible reduction in mortality, however, the results did not quite achieve statistical significance RR, 0. We rated the overall evidence as high because effects were favorable across outcomes and the reduction in mortality was nearly statistically significant.

Any additional benefit from aggressive BP control is small, with a lower magnitude of benefit and inconsistent results across outcomes. Although this guideline did not specifically address pharmacologic versus nonpharmacologic treatments for hypertension, several nonpharmacologic treatment strategies are available for consideration. Effective nonpharmacologic options for reducing BP include such lifestyle modifications as weight loss, such dietary changes as the DASH Dietary Approaches to Stop Hypertension diet, and an increase in physical activity.

Nonpharmacologic options are typically associated with fewer side effects than pharmacologic therapies and have other positive effects; ideally, they are included as the first therapy or used concurrently with drug therapy for most patients with hypertension. Most of the included studies measured seated BP after 5 minutes of rest and used multiple readings.

Guideline Focus and Target Population

Clinicians should ensure that they are accurately measuring BP before beginning or changing treatment of hypertension. Assessment may include multiple measurements in clinical settings for example, 2 to 3 readings separated by 1 minute in a seated patient who is resting alone in a room or ambulatory or home monitoring An SBP target of less than mm Hg is a reasonable goal for some patients with increased cardiovascular risk. While pooled estimates of all studies demonstrated no statistically significant reductions in mortality, cardiac events, or stroke a single large, high quality study SPRINT did find benefits across all outcomes in high risk individuals without diabetes.

The target depends on many factors unique to each patient, including comorbidity, medication burden, risk for adverse events, and cost. Clinicians should individually assess cardiovascular risk for patients. This trial found that targeting SBP to less than mm Hg compared with less than mm Hg in adults without diabetes or prior stroke, at high-risk for cardiovascular disease, and with a baseline SBP of less than mm Hg significantly reduced fatal and nonfatal cardiovascular events and all-cause mortality.

In contrast, ACCORD 40 included only adults with type 2 diabetes and found no statistically significant reduction in the primary composite outcome of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular events RR, 0. This study did find a reduction in stroke events RR, 0. In light of the low quality evidence of no statistically significant reduction in mortality, cardiac events, or stroke from pooled estimates from all studies, but benefit shown by SPRINT, as well as the known harms, burden, and costs of more intensive pharmacological therapy, an individualized assessment is important to evaluate the benefit of lower blood pressure targets relative to harms in patients age 60 years and older.

No trials assessed the relationship between multiple comorbid conditions and the benefits and harms of treating BP to different targets. Patients with a high comorbidity burden were probably not included in the overall group of studies. Many studies excluded patients with various comorbid conditions, such as diabetes, insulin use, recent coronary events, heart failure, or chronic kidney disease, and most studies had criteria that would implicitly or explicitly exclude those with dementia or diminished functional status. Evidence was insufficient for targeting treatment according to DBP. Individual assessment of benefits and harms is particularly important in adults aged 60 years or older with multiple chronic conditions, several medications, or frailty.

These patients might theoretically benefit from more aggressive BP treatment because of higher cardiovascular risks. However, they are more likely to be susceptible to serious harm from higher rates of syncope and hypotension, which were seen in some trials. Moreover, the absolute benefits of more aggressive BP treatment in elderly persons, those with multimorbidity, or those who are frail are not well-known, given limitations of the trials.

These patients often receive multiple medications and are on drug regimens that are difficult to manage and increase the cost and risk for drug interactions. Indeed, most trials had exclusion criteria that implicitly or explicitly excluded patients who had dementia or diminished functional status. Few trials were available to compare patients with and without diabetes, which made drawing conclusions about relative treatment effects in these populations difficult.

Hypertension - Clinical Practice Guideline -- Clinical Recommendation

Although some benefit is achieved by aiming for lower BP targets, most benefit occurs with acceptable harms and costs in the pharmacologic treatment of patients who have an SBP of mm Hg or greater. When prescribing drug therapy, clinicians should select generic formulations over brand-name drugs, which have similar efficacy, reduced cost, and therefore better adherence Clinicians should consider the patient's treatment burden when deciding on treatment options.

Studies have correlated multiple doses of hypertensive medications with poorer medication adherence 47 , The balance of benefits and harms identified in our evidence report is based in part on rigorous and accurate assessment of BP. Therefore, it is important to ensure accurate BP measurement before initiating or changing treatment of hypertension.

The most accurate measurements come from multiple BP measurements made over time. KQ 1: In adults aged 60 years or older, what are the health outcome effects of differing BP targets? KQ 2: How does age modify the benefits of differing BP targets? KQ 3: How does the patient burden of comorbid conditions modify the benefits of differing BP targets?

The JNC 8 Hypertension Guidelines: An In-Depth Guide

KQ 4: What are the harms of targeting lower BP in older patients? Do the harms vary with age? KQ 5: Do the harms of targeting lower BP vary with patient burden of comorbid conditions?

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  4. Observational studies were excluded from analysis of such health outcomes as mortality, stroke, and cardiovascular events. For additional information, including inclusion and exclusion criteria, refer to the accompanying article 8 and full report 9. The reviewers conducted a meta-analysis on study-level data using the random-effects model. They also conducted individual-patient data meta-analysis to assess treatment according to age subgroups.

    The quality of studies was assessed using the Cochrane risk-of-bias tool The evidence reviewers graded the quality of evidence using the Agency for Healthcare Research and Quality system Adults aged 60 years or older with a diagnosis of hypertension were studied. The comparator was less intensive BP treatment.

    Evaluated outcomes included all-cause mortality; cardiac events myocardial infarction and sudden cardiac death ; morbidity and mortality related to stroke; and harms, including cognitive impairment, quality of life, falls, fractures, syncope, functional status, hypotension, acute kidney injury defined as the doubling of serum creatinine or need for renal replacement therapy , medication burden, and withdrawal due to adverse events.

    Controlled study designs randomized, controlled trials and nonrandomized, controlled trials KQs 1, 2, 3, 4 and 5 and cohort studies KQs 4 and 5 were included. Case reports; case series; randomized, controlled trials with less than 6-month follow-up; and controlled before—after studies were excluded. The VA evidence review was sent to invited peer reviewers and posted on the VA Web site for public comments, and the published review article was peer reviewed through the journal.

    The guideline had a peer-review process through the journal and was posted online for comments from ACP Regents and Governors, who represent physician members at the national level.

    Heart disease and stroke statistics— update: a report from the American Heart Association. Results in patients with diastolic blood pressures averaging through mm Hg. Medical Research Council trial of treatment of hypertension in older adults: principal results. MRC Working Party. The Australian therapeutic trial in mild hypertension. Report by the Management Committee.