Controversies in Cardiology: Blood Pressure Targets in Hypertension

Harrington Heart & Vascular Institute Innovations - Winter 2016

Daniel I. Simon, MD

Jackson T. Wright JR., MD, PHD

DANIEL SIMON, MD: I would like to welcome Jackson T. Wright Jr., MD, PhD, Director, Clinical Hypertension Program, and Director, Dahms Clinical Research Unit, UH Case Medical Center; Professor of Medicine, Case Western Reserve University School of Medicine to our Controversies in Cardiology series. Dr. Wright is an internationally renowned luminary in hypertension, one of the primary investigators of the NHLBIsponsored* ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), which concluded that thiazide-type diuretics are superior in preventing cardiovascular disease and should be preferred for first-step antihypertensive therapy.

JACKSON WRIGHT JR., MD, PHD: Yes, Dan. The JNC-8 (Joint National Committee) relaxed the blood pressure targets in two key groups, the elderly and those younger than 60 with diabetes or kidney disease. For patients age 60 and older, the JNC-8 guidelines recommend treating to a target of 150/90 mm Hg rather than 140/90 mm Hg. In patients with diabetes or kidney disease, JNC-8 guidelines recommend treating to 140/90 mm Hg rather than lower blood pressure targets (i.e., 135/85 mm Hg).

DR. SIMON: Many of us do not completely understand the rationale for the guideline change. In fact, our uncertainty in the new hypertension treatment guidelines carries over to our confusion in the new hyperlipidemia treatment recommendations, which eliminated hard LDL targets in primary (less than 100 mg/dL) and secondary (less than 70 mg/dL) prevention. What antihypertensive medication do you recommend as first agent? What is your second medication of choice, recognizing that most patients require at least two antihypertensive medications for adequate control??

DR. WRIGHT: I would start with a thiazide diuretic like chlorthalidone. For a second agent, I would recommend a drug that has been shown to reduce cardiovascular events, such as a calcium channel blocker, ACE inhibitor or ARB.

DR. SIMON: What do you recommend for patients with resistant hypertension?

DR. WRIGHT: Approximately 10 percent of patients with hypertension have resistant hypertension, defined as a blood pressure that remains above goal in spite of the concurrent use of three antihypertensive agents of different classes, including a diuretic at an appropriate dose. Patients with resistant hypertension have high rates of cardiovascular complications. In my experience, many patients are misclassified as having resistant hypertension. It is important to titrate antihypertensive medications to maximally tolerated recommended dosages and to strongly consider the addition of spironolactone, which is particularly effective in helping patients achieve blood pressure treatment goals. 

DR. SIMON: The NHLBI just issued a press release regarding SPRINT (Systolic Blood Pressure Intervention Trial). You are one of the principal investigators of SPRINT. Fill us in on this landmark announcement. 

DR. WRIGHT: The results of SPRINT are very exciting. This study shows that intensive blood pressure management can prevent the cardiovascular complications of hypertension and save lives. As the NHLBI reported, treating high-risk hypertensive adults age 50 and older reduced cardiovascular events by 30 percent and reduced all-cause mortality by nearly 25 percent when compared with patients treated to a systolic target of 140 mm Hg. SPRINT was designed as a target-based study, which gave physicians flexibility in selecting antihypertensive medications to achieve the assigned blood pressure target. Hypertensive patients with a 10-year Framingham General cardiovascular risk ?15%, age >75 years of age or pre-existing kidney disease were randomized to intensive blood pressure control (less than 120 mm Hg) or standard blood pressure control (less than 140 mm Hg). In the intensive-therapy arm, patients were treated with three or more antihypertensive medications, including diuretics, calcium channel blockers and ACE inhibitors. You can read more about the SPRINT results in the Nov. 26, 2015, issue of The New England Journal of Medicine. 

DR. SIMON: Congratulations to you, Jackson, and the SPRINT investigators. We look forward to inviting you back to discuss how the results of SPRINT will change clinical practice. I suspect guideline writers will be huddling closely in the coming months.