Skip to main content

Advertisement

SpringerLink
Log in

Intensive antihypertensive treatment to the new lower blood pressure targets

  • Published:
Current Hypertension Reports Aims and scope Submit manuscript

Abstract

The recommendations of several authoritative bodies that blood pressure be lowered to lower-than-traditional goals in patients with high-risk hypertension have recently been validated by data from several randomized clinical trials. In the Hypertension Optimal Treatment (HOT) trial, the best prognosis was in diabetic patients treated to a diastolic blood pressure of 80 mm Hg. In the United Kingdom Prospective Diabetes Study 38, a major reduction in nearly every type of cardiovascular event was noted among patients with type II diabetes who were treated to the lower blood pressure goal of less than 150/85 mm Hg. In the quality-of-life substudy of the HOT trial, the greatest improvement was found in patients treated to the lowest diastolic blood pressure goal of less than or equal to 80 mm Hg. Two economic analyses suggest that attainment of the lower blood pressure goal not only is possible and effective in reducing cardiovascular risk but also saves money overall by reducing expenditures for stroke, myocardial infarction, and other cardiovascular events.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). Arch Intern Med 1997, 157:2413–2446. The consensus report of the US National Expert Panel on hypertension and its management recommends immediate drug therapy for high-risk patients with blood pressures as low as 130/85 mm Hg. It also recommends target blood pressures of less than 130/85 mm Hg for diabetic and renally impaired patients and less than 125/75 mm Hg for patients with proteinuria (protein excretion> 1 g/d).

  2. Stewart IMDG: Relation of reduction in pressure to first myocardial infarction in patients receiving treatment for severe hypertension. Lancet 1979, 1:861–865.

    Article  PubMed  CAS  Google Scholar 

  3. McCloskey LW, Psaty BM, Koepsell TD, Aagaar GN: Level of blood pressure and risk of myocardial infarction among treated hypertensive patients. Arch Intern Med 1992, 152:513–520.

    Article  PubMed  CAS  Google Scholar 

  4. Cruickshank JM, Thorpe JM, Zacharias FJ: Benefits and potential harm of lowering high blood pressure. Lancet 1987, 1:581–584.

    Article  PubMed  CAS  Google Scholar 

  5. Farnett L, Mulrow CD, Linn WD, et al.: The J-curve phenomenon and the treatment of hypertension. Is there a point beyond which pressure reduction is dangerous? JAMA 1991, 265:489–495.

    Article  PubMed  CAS  Google Scholar 

  6. Fletcher AE, Bulpitt CJ: How far should blood pressure be lowered? N Engl J Med 1992, 326:251–254.

    Article  PubMed  CAS  Google Scholar 

  7. Hansson L: The BBB study: the effect of intensified antihypertensive treatment on the level of blood pressure, side-effects, morbidity and mortality in "well-treated" hypertensive patients. Behandla Blodtryck Battre. Blood Pressure 1994, 3:248–254.

    Google Scholar 

  8. Hansson L, Zanchetti A, Julius S, et al.: Effects of intensive blood pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998, 351:1755–1762. This study showed no difference in major cardiovascular events among 18,790 patients with hypertension randomly assigned to one of three target diastolic blood pressures: 80, 85, or 90 mm Hg. "Optimal blood pressure" for most hypertensive patients was found to be 138.5/82.6 mm Hg. Half of the patients in the trial received aspirin, 75 mg/d, which was associated with a significant 15% reduction in risk for major cardiovascular events compared with placebo. Perhaps most important, the 1501 diabetic patients in this study had a significant benefit with respect to avoiding a major cardiovascular event. The best protection was seen in the group assigned to the lowest blood pressure goal (80 mm Hg).

    Article  PubMed  CAS  Google Scholar 

  9. Wiklund I, Halling K, Ryden-Bergsten T, Fletcher A: Does lowering the blood pressure improve the mood? Quality-of-life results from the Hypertension Optimal Treatment (HOT) Study. Blood Pressure 1997, 6:357–364.

    PubMed  CAS  Google Scholar 

  10. Kaplan N: J-curve not burned off by HOT Study. Hypertension Optimal Treatment [editorial]. Lancet 1998, 351:1758–1749.

    Google Scholar 

  11. The Systolic Hypertension in the Elderly Program Cooperative Study Group: Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA 1991, 265:3255–3264.

    Article  Google Scholar 

  12. Staessen JA, Fagard R, Thijs L, et al.: Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997, 350:757–764.

    Article  PubMed  CAS  Google Scholar 

  13. Liu L, Wang J, Gong L, et al.: Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. J Hypertens 1998, 16:1823–1829.

    Article  PubMed  CAS  Google Scholar 

  14. Toumilehto J, Rastenyte D, Birkenhäger WH, et al.: Effects of calcium channel blockade in older patients with diabetes and systolic hypertension. N Engl J Med 1999, 340:677–684.

    Article  Google Scholar 

  15. Curb DB, Pressel SL, Cutler JA, et al.: Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA 1996, 276:1886–1892.

    Article  PubMed  CAS  Google Scholar 

  16. Alderman M: Blood pressure management: individualized treatment based on absolute risk and the potential for benefit. Ann Intern Med 1993, 119:329–335.

    PubMed  CAS  Google Scholar 

  17. Lever AF, Ramsay LE: Treatment of hypertension in the elderly. J Hypertens 1995, 13:571–579.

    Article  PubMed  CAS  Google Scholar 

  18. Chatellier G, Ménard J: The absolute risk as a guide to influence the treatment decision-making process in mild hypertension. J Hypertens 1997, 15:217–219.

    Article  PubMed  CAS  Google Scholar 

  19. Klahr S, Levey AS, Beck GJ, et al.: The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med 1994, 330:877–884.

    Article  PubMed  CAS  Google Scholar 

  20. Lazarus JM, Bourgoignie JJ, Buckalew VM, et al.: Achievement and safety of a low blood pressure goal in chronic renal disease: the Modification of Diet in Renal Disease Study Group. Hypertension 1997, 29:641–650. In this study, 585 renally-impaired patients (baseline glomerular filtration rate, 13–55 mL/min) were randomly assigned to a target mean arterial pressure of 107 or 92 mm Hg. Although more changes in blood pressure medications and symptoms were seen in the group with the lower target, this group had a significantly lower risk for hospitalization and progression of renal disease. This was the first randomized study to suggest that a blood pressure of less than 125/75 mm Hg is beneficial in renally-impaired patients with proteinuria (protein excretion> 1 g/d).

    PubMed  CAS  Google Scholar 

  21. Jacobson HR, Striker GE: Report on a workshop to develop management recommendations for the prevention of progression in chronic renal disease. Am J Kidney Dis 1995, 25:153–156. The National Kidney Foundation recommends a lower blood pressure goal for patients with renal impairment.

    Google Scholar 

  22. Turner R, Holman R, Stratton I, et al.: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. United Kingdom Prospective Diabetes Study Group. BMJ 1998, 317:707–713. In the United Kingdom, 1148 persons with type II diabetes were randomly assigned to target blood press ures of 180/105 mm Hg or 150/ 85 mm Hg and then followed for 8.4 years. Those treated to the lower goal (achieved blood pressure average of 144/82 mm Hg) had 32% fewer deaths, 44% fewer strokes, 24% fewer diabetes-related end points, and 37% fewer microvascular end points than the group treated to the higher goal (achieved blood pressure average of 154/87 mm Hg). This study provides strong evidence that lower blood pressure, regardless of which drug is used first, prevents cardiovascular events in diabetic patients.

    Google Scholar 

  23. Elliott WJ, Weir DR, Black HR: Cost-effectiveness of the new treatment goal of JNC VI for diabetics and the renallyimpaired [abstract]. Am J Hypertens 1998, 11:8A. A 24-state Markov model was used to estimate costs and benefits for a cohort of diabetic or renally impaired hypertensive patients whose blood pressure is lowered to less than 130/85 mm Hg instead of to the older goal of less than 140/90 mm Hg. For 60-year-old persons, the cost per year of life saved by lowering blood pressure to the new goal was-$3020. Life expectancy increased by 0.48 years, and lifetime health care costs decreased by $1450. The cost-effectiveness ratio of the new blood pressure goal is more favorable than that of many common medical interventions; the lower goal actually saves money in older hypertensive patients across a wide variety of initial assumptions.

    Article  Google Scholar 

  24. Raikou M, Gray A, Briggs A, et al.: Cost effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes: UKPDS 40. United Kingdom Prospective Diabetes Study Group. BMJ 1998, 317:720–726. The costs of additional medications and medical services were compared with the costs of complications of diabetes in the patients randomly assigned to the two blood pressure targets (less than 180/ 105 mm Hg and less than 150/85 mm Hg) in the UKPDS 38 study. The lower goal was associated with overall cost savings; the cost per year of life saved was negative £720, and the cost per year of life without complications of diabetes was negative £1049.

    Google Scholar 

  25. Weinstein MC, Seigel JE, Gold MR, et al.: Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA 1996, 276:1253–1258.

    Article  PubMed  CAS  Google Scholar 

  26. American Diabetes Association: Standards of medical care for patients with diabetes mellitus. Diabetes Care 1998, 21(suppl):S23-S31. The American Diabetes Association recommends a lower blood pressure goal for diabetic patients than for nondiabetic patients.

    Article  Google Scholar 

  27. Siegel D, Lopez J: Trends in antihypertensive drug use in the United States: do the JNC V recommendations affect prescribing? JAMA 1997, 278:1745–1748.

    Article  PubMed  CAS  Google Scholar 

  28. National Committee for Quality Assurance (NCQA): HEDIS 3.0, v. 1. In Washington, DC: National Committee for Quality Assurance; 1997.

    Google Scholar 

  29. Grimaldi PL: New HEDIS means more information about HMOs. J Health Care Financ 1997, 23:40–50.

    CAS  Google Scholar 

  30. Bodenheimer T: The American health care system—the movement for improved quality in health care. N Engl J Med 1999, 340:488–492.

    Article  PubMed  CAS  Google Scholar 

  31. Epstein AM: Rolling down the runway: the challenges ahead for quality report cards. JAMA 1998, 279:1691–1696.

    Article  PubMed  CAS  Google Scholar 

  32. Chassin MR, Galvin RW: The urgent need to improve health care quality. JAMA 1998, 280:1000–1005.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Preventive Medicine, RUSH Medical College of RUSH University, 1725 West Harrison Street, Suite 117, 60612, Chicago, IL, USA

    William J. Elliott MD, PhD

Authors
  1. William J. Elliott MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Elliott, W.J. Intensive antihypertensive treatment to the new lower blood pressure targets. Current Science Inc 1, 313–319 (1999). https://doi.org/10.1007/s11906-999-0039-0

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11906-999-0039-0

Keywords

Search

Navigation