Aram V. Chobanian’s research while affiliated with University of Massachusetts Boston and other places

This article summarizes pertinent data from clinical trials on the effects of antihypertensive therapy on cardiovascular complications. Prior definitions of hypertension and blood pressure goals of therapy are discussed, and differences between national and international guidelines on such goals are summarized. The results of the SPRINT study are summarized, and the impact of this study on future goals of treatment is discussed. New recommendations are provided on blood pressure goals, and the effects such goals might have on clinical practice are discussed.

Setting blood pressure (BP) goals is not an exact science. Such goals have generally relied on findings from clinical trials that typically have differed in such important variables as age of participants, entry and exclusion criteria, presence or absence of concomitant illnesses, severity of hypertension, treatment regimens, and therapeutic goals. Furthermore, few previous trials have been designed to compare the effects of lowering BP to different targets. Controversy exists currently on BP goals. For several years following publication of the JNC 7 report,1 there appeared to be consensus regarding a goal BP of less than 140/90 mm Hg for most persons with hypertension, irrespective of age, and levels of less than 130/80 mm Hg for those with diabetes, chronic renal diseases, and certain cardiovascular conditions. However, 3 major groups have since made new and differing recommendations regarding BP goals, particularly in older persons, and the results of new trials have become available. The JNC 8 committee raised the systolic BP (SBP) goal for those aged 60 years or older to less than 150 mm Hg.2 The European Society of Hypertension/European Society of Cardiology joint committee advocated a goal of less than 140 to 150 mm Hg for those aged 80 years or older.3 A joint committee representing the American Society of Hypertension and the International Society of Hypertension recommended a target of less than 150/90 mm Hg for those aged 80 years or older.4

In this issue of JAMA, Williamson and colleagues¹ report the results of a preplanned, appropriately powered subgroup analysis of data from the Systolic Blood Pressure intervention Trial (SPRINT) in persons aged 75 years or older. SPRINT was a randomized, clinical, open-label study of community-dwelling older adults with systolic blood pressure (SBP) in the 130 to 180 mm Hg range in whom the effects of reducing SBP to less than 120 mm Hg (intensive treatment group) were compared with those associated with SBP lowering to less than 140 mm Hg (standard treatment group).² The primary end point was a composite of cardiovascular disease (CVD) events, including myocardial infarction, acute coronary syndrome, heart failure, stroke, or death from cardiovascular causes. Exclusion criteria included diabetes, history of stroke or heart failure, and SBP less than 110 mm Hg after 1 minute of standing.

More than 70 million people in the United States and more than 1 billion worldwide have hypertension - defined by a systolic blood pressure of at least 140 mm Hg and a diastolic blood pressure of at least 90 mm Hg - and the numbers are increasing steadily. Despite remarkable advances in pharmacotherapy, which have given us the ability to lower elevated blood pressure in almost everyone, hypertension remains a major public health problem as a critically important risk factor for cardiovascular and renal disease. Benefits of antihypertensive drug therapy were first demonstrated in the late 1950s in patients with . . .

See related article, pp 1061–1068 The management of hypertension has represented one of the most important therapeutic successes of the past 50 to 60 years. The capability now exists to lower blood pressure (BP) effectively and with relatively minimal adverse effects in most hypertensive individuals. The debate regarding therapy has shifted from whether lowering BP is beneficial to such issues as the relative benefits and risks of individual antihypertensive medications, their long-term effects on cardiovascular disease (CVD) and chronic renal disease outcomes, and the optimal BP goals of therapy in different clinical conditions. Based on extensive clinical trial data, general agreement has existed that lowering elevated BP to <140 mm Hg systolic and 90 mm Hg diastolic BP is beneficial. Lower BP goals have been suggested on the basis of epidemiological and observational data indicating that CVD risk increases progressively from BP levels as low as 115/75 mm Hg.1 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommended a goal BP of ≤130/80 mm Hg in hypertensive patients with chronic renal disease or diabetes mellitus,2 consistent with the recommendations of the National Kidney Foundation and the American Diabetes Association. Subsequently, the American Heart Association expanded this list by recommending BP targets <130/80 mm Hg for patients with preexisting coronary heart diseases, angina pectoris, and acute coronary syndromes or those at high risk for CVD, and BP <120/80 mm Hg for those with left ventricular dysfunction.3 Generally similar recommendations have been made by other national or international groups as well. However, the available evidence may not justify such an aggressive approach. For example, the African American Study of Kidney Disease and Hypertension compared the effects of goal BP of ≤140/90 …

Hypertension has long been recognized as a major risk factor for cardiovascular diseases. Advances in drug therapy have provided clinicians with the ability to lower blood pressure (BP) to goal levels in most persons with hypertension. In addition, many intervention trials have demonstrated large benefits of BP lowering in reducing the incidence of cardiovascular events independently of age, sex, type or severity of hypertension, or presence of comorbid conditions.1 Nevertheless, the control of hypertension in the United States and throughout the world has been grossly inadequate.

The benefits of antihypertensive therapy in reducing cardiovascular complications have been impressive. Several clinical trials in hypertension have shown that reduction of blood pressure is associated with significant decreases in the incidence of stroke, ischemic heart disease, congestive heart failure, and renal failure, irrespective of age, gender, race or ethnicity, type of antihypertensive used, or severity of hypertension.1 Nevertheless, control of hypertension remains unsatisfactory in the United States and throughout the world. Recent data from the National Health and Nutrition Examination Survey indicate that approximately 40% of hypertensive individuals are untreated, and 65% do not have their hypertension controlled to a blood pressure level of <140/90 mm Hg.2 Although control rates have improved in the past several years, the total number of patients with uncontrolled hypertension has actually increased because of the rise in hypertension prevalence during this period (Figure).3 Figure. Changes in the prevalence and control of hypertension in the United States (1988–2004). The total number of persons with uncontrolled hypertension has increased from 37 million to 42 million during the past 2 decades, even though the rate of control has increased from 27% to 35% during the same period. Data are from Cutler et al2 and Chobanian.3 Reprinted from Chobanian.3 Article see p 1598 The capability currently exists to lower blood pressure to goal levels in most hypertensive individuals. As with the treatment of other chronic illnesses in which long-term treatment is required, adherence to prescribed medications for hypertension can be a problem. Studies have shown that ≈50% of individuals discontinue antihypertensive medications within 6 to 12 months of their initiation.4 It has been assumed that inadequate adherence to antihypertensive medications and lack of persistence of therapy contribute to the development of cardiovascular complications, although little information has been available …