COMMENTARY

Blood Pressure Goals: Is 140 Good Enough for Everyone?

George Bakris, MD; Rajiv Agarwal, MD

Disclosures

October 28, 2011

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George Bakris, MD: Hello. I'm Dr. George Bakris, Professor of Medicine and Director of the Hypertensive Diseases Unit at the University of Chicago, Pritzker School of Medicine. I am joined today by Dr. Rajiv Agarwal, Professor of Medicine in the Nephrology Division at Indiana University. Rajiv, good morning.

Rajiv Agarwal, MD: Good morning, George.

Dr. Bakris: One of the topics that's really become very hot and is something that we need to think about is the level of blood pressure. There's been a groundswell of evidence that less than 140 mm Hg is perfectly appropriate. We do not need to go to less than 130 mm Hg, even in diabetes. Certainly the National Institute for Health and Clinical Excellence (NICE) guidelines[1] have this information in their recent update and JNC 8 is certainly going to talk about this as well. Where do we stand on this?

Dr. Agarwal: A number of studies now suggest that more aggressive lowering of blood pressure down to 130/80 mm Hg in diabetics and people with common kidney disease may not be any more useful than simply lowering their blood pressure to less than 140/90 mm Hg. First of all, it's hard to get the blood pressure down to less than 130/80 mm Hg. It requires a lot of resources. More medications are more expensive. When you [aim for] a lower blood pressure target, you're more likely to have more hypotensive events, etcetera. So, it's not translated into a net benefit for the patient.

I agree with the guidelines that it seems reasonable at the current state of our knowledge to target the blood pressure to less than 140/90 mm Hg, but the guidelines are somewhat schizophrenic on which blood pressure should be treated. For example, the NICE guidelines are telling us that we should confirm the diagnosis of hypertension using ambulatory blood pressure monitoring, but all of the treatment is being done with the clinic blood pressure monitoring. I realize that there are limited data on using home blood pressure to guide therapy, but at least there is a very nice trial done in the United Kingdom that was published in TheLancet by McManus and associates[2] that showed that if you used home blood pressure monitoring and allowed patients to self-titrate their medications to achieve a particular goal -- similar to insulin therapy -- people had better blood pressure control at the end of 6 months or 1 year. So, I'm all for using home blood pressure monitoring to guide therapy as well, instead of just making a diagnosis. If you are going to do that, then the target at home should be less than 135/85 mm Hg, which is 5 mm lower than what you typically see in the clinic.

Dr. Bakris: Yes, that's very good. In fact, I do that all the time and I think a lot of hypertension specialists do that as well, because then the patient is actively participating and it approves adherence as well. There's one exception to the < 140/90 mm Hg, and that is people with proteinuria, usually with chronic kidney disease and, specifically, proteinuria at levels well above 300 mg/L a day and certainly up to 500 mg/L and higher. Admittedly, mostly nephrologists see these patients, although they are in diabetes clinics and they may even be seen in the primary care setting. In that circumstance the data are pretty clear that less than 130 mm Hg still is the goal and still should be there. That's supposedly evidence based, although not level 1A evidence. It's mostly retrospective, but there are a number of trials that are very consistent on this and it correlates with better outcome if you can reduce proteinuria. What are your thoughts about that?

Dr. Agarwal: So, the evidence for proteinuric patients is also based on some retrospective analyses of these clinical trials. I'm not aware of any trial that has prospectively randomized patients based on proteinuria to two different levels of blood pressure control and looked at outcomes.

Dr. Bakris: That's correct.

Dr. Agarwal: Even the meta-analysis that Katrin Uhlig championed in Annals of Internal Medicine[3] says that perhaps that's one area that we can target a lower blood pressure, but that's also optional. So, it's very hard to get the blood pressure down in the nephrotic patient, and if we can successfully get the blood pressure down to less than 135/85 mm Hg at home, I'm pretty happy with that outcome. Clearly the lower the blood pressure gets the better the outcome, but targeting a lower blood pressure versus achieving a lower blood pressure are two different things. So, it's hard to say which is cause and effect but if you can control blood pressure at home to less than 135/85 mm Hg, I think you have done 90% of the job.

Dr. Bakris: Yeah. I would agree with that. It is tough. I certainly aim to do it and I can achieve it in probably 75%-80% of the cases, but it takes me 6 drugs to do it. So, the patient needs to understand that it's a pretty lofty goal, but in those than can achieve it and tolerate it, they do quite well. So, again it's the person's physiology that is going to limit what you can and cannot do in terms of the blood pressure. So, I think that's a very good point. Well Rajiv, thank you very much for talking with me today on this very important topic, which is certainly going to be in the forefront for the next year or two with the guidelines coming out in JNC 8. Thank you for joining us today. I'm Dr. George Bakris from the University of Chicago, and on behalf of myself and Dr. Agarwal I want to thank you very much. Thank you and have a good day.

Dr. Agarwal: Thank you, George, for inviting me to participate in this conference.

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