Protocol for Past BP: a randomised controlled trial of different blood pressure targets for people with a history of stroke of transient ischaemic attack (TIA) in primary care Reasons for therapeutic inertia when managing hypertension in clinical practice in non-Western countries Blood pressure telemonitoring is useful to achieve blood pressure control in inadequately treated patients with arterial hypertension A Randomized Trial of Intensive versus Standard Blood-Pressure Control. Progress Report on the Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP) Study: Status at February 2004 Selective recording in blood pressure readings may increase subsequent mortality. Baseline Characteristics and Early Blood Pressure Control in the CONVINCE Trial The validity of emergency department triage blood pressure measurements. Self-monitoring of blood pressure promotes achievement of blood pressure target in primary health care. Effect of a Community Health Worker–Led Multicomponent Intervention on Blood Pressure Control in Low-Income Patients in Argentina: A Randomized Clinical Trial Achievement and safety of a low blood pressure goal in chronic renal disease. The Modification of Diet in Renal Disease Study Group. Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in Patients Aged 60 Years or Older: The Minority View Physician and pharmacist collaboration to improve blood pressure control. Systolic blood pressure is superior to other haemodynamic predictors of outcome in community acquired pneumonia A multicenter, randomized, double-blind comparison of the efficacy and safety of irbesartan and enalapril in adults with mild to moderate essential hypertension, as assessed by ambulatory blood pressure monitoring: the MAPAVEL Study (Monitorización Ambulatoria Presión Arterial APROVEL). Effects of intensive antihypertensive treatment on Chinese hypertensive patients older than 70 years. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial.
Background Blood pressure ( BP ) lowering in people who have had a stroke or transient ischaemic attack ( TIA ) leads to reduced risk of further stroke . However , it is not clear what the target BP should be , since intensification of therapy may lead to additional adverse effects . PAST BP will determine whether more intensive BP targets can be achieved in a primary care setting , and whether more intensive therapy is associated with adverse effects on quality of life . Methods / Design This is a r and omised controlled trial ( RCT ) in patients with a past history of stroke or TIA . Patients will be r and omised to two groups and will either have their blood pressure ( BP ) lowered intensively to a target of 130 mmHg systolic , ( or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg ) compared to a st and ard group where the BP will be reduced to a target of 140 mmHg systolic . Patients will be managed by their practice at 1 - 3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months.610 patients will be recruited from approximately 50 general practice s. The following exclusion criteria will be applied : systolic BP < 125 mmHg at baseline , 3 or more anti-hypertensive agents , orthostatic hypotension , diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness . The primary outcome will be change in systolic BP over twelve months . Secondary outcomes include quality of life , adverse events and cardiovascular events . In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals underst and ing and views of BP management . Discussion The results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care , and help determine whether or not further research is required before recommending such targets for this population .Trial Registration IS RCT Insufficient awareness of hypertension guidelines by physicians may be an impediment to achieving adequate blood pressure ( BP ) control rates in clinical practice . We therefore conducted an open intervention survey among primary care physicians in 1596 centres from 16 countries in four different continents to prospect ively assess what is the BP goal defined by physicians for individual patients and what are the reasons for not intensifying antihypertensive treatment when BP goals are not achieved . Enrolled patients ( N=35 302 ) were either not treated to goal ( N=22 887 ) or previously untreated ( N=12 250 ) . Baseline systolic and diastolic BP averaged 159/95±15/12 mm Hg . BP goals defined by physicians averaged 136±6 mm Hg for systolic and 86±5 mm Hg for diastolic BP . Patients ' individual risk stratification determined BP goals . At last visit BP averaged 132/81±11/8 mm Hg and values of ⩽140/90 were reached in 92 % of untreated and 80 % of previously uncontrolled treated hypertensives . The main reasons for not intensifying antihypertensive treatment when BP remained above goal were the assumption that the time after starting the new drug was too short to attain its full effect , the satisfaction with a clear improvement of BP or with a BP nearing the goal , and the acceptance of good self- measurements . In this open intervention program in primary care , a large proportion of patients achieved recommended BP goals . The belief that a clear improvement in BP is acceptable and that the full drug effect may take up to several weeks to be reached are frequent reasons for treatment inertia when goals are not achieved Failing to reach blood pressure ( BP ) goals is one of the main problems in hypertension management . Especially in high-risk patients , intensive monitoring including frequently office visits or new techniques to monitor home BP is required . A total of 60 patients with uncontrolled hypertension were included and r and omized into a group with  telemetric BP monitoring ( TBPM ) ( n=30 ) and a control group receiving st and ard care ( n=30 ) . During the 3-month study period , patients received in addition to their antihypertensive pre-treatment up to 2 × 300 mg irbesartan to achieve the required target BP . All patients were instructed to measure their BP once daily in the morning . In the TBPM group automatic alerts were generated by the central data base server using pre-defined algorithms and patients were subsequently contacted by the physician . At baseline mean 24-h ambulant BP monitoring ( ABPM ) was 143.3±11.1/82.6±9.9 mm Hg in the TBPM group and 141.4±12.6/82.1±6.5 mm Hg in the st and ard care group . During treatment mean systolic BP showed a more intensive decrease in the TBPM vs control group ( −17.0±11.1 mm Hg vs −9.8±13.7 mm Hg ; P=0.032 ) . Patients in the TBPM group had a more pronounced night dipping and a higher reduction of mean pulse pressure than controls ( −8.1±5.9 mm Hg vs −2.8±7.4 mm Hg , P=0.004 ) . After 3 months , TBPM-treated patients were given a higher mean daily dose of irbesartan ( 375±187 mg vs 222±147 mg in controls ; P=<0.001 ) . We demonstrated that with TBPM a more effective and faster titration of the antihypertensive agent is possible . The alarm criteria chosen were useful to improve BP control BACKGROUND The most appropriate targets for systolic blood pressure to reduce cardiovascular morbidity and mortality among persons without diabetes remain uncertain . METHODS We r and omly assigned 9361 persons with a systolic blood pressure of 130 mm Hg or higher and an increased cardiovascular risk , but without diabetes , to a systolic blood-pressure target of less than 120 mm Hg ( intensive treatment ) or a target of less than 140 mm Hg ( st and ard treatment ) . The primary composite outcome was myocardial infa rct ion , other acute coronary syndromes , stroke , heart failure , or death from cardiovascular causes . RESULTS At 1 year , the mean systolic blood pressure was 121.4 mm Hg in the intensive-treatment group and 136.2 mm Hg in the st and ard-treatment group . The intervention was stopped early after a median follow-up of 3.26 years owing to a significantly lower rate of the primary composite outcome in the intensive-treatment group than in the st and ard-treatment group ( 1.65 % per year vs. 2.19 % per year ; hazard ratio with intensive treatment , 0.75 ; 95 % confidence interval [ CI ] , 0.64 to 0.89 ; P<0.001 ) . All-cause mortality was also significantly lower in the intensive-treatment group ( hazard ratio , 0.73 ; 95 % CI , 0.60 to 0.90 ; P=0.003 ) . Rates of serious adverse events of hypotension , syncope , electrolyte abnormalities , and acute kidney injury or failure , but not of injurious falls , were higher in the intensive-treatment group than in the st and ard-treatment group . CONCLUSIONS Among patients at high risk for cardiovascular events but without diabetes , targeting a systolic blood pressure of less than 120 mm Hg , as compared with less than 140 mm Hg , result ed in lower rates of fatal and nonfatal major cardiovascular events and death from any cause , although significantly higher rates of some adverse events were observed in the intensive-treatment group . ( Funded by the National Institutes of Health ; Clinical Trials.gov number , NCT01206062 . ) The Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressure ( HOMED-BP ) Study is the first large-scale intervention trial in Japan using a PROBE design to determine an optimal target blood pressure ( BP ) level on the basis of self-measured BP at home and optimal initial antihypertensive medication . The registered patients are r and omized to one of two different BP levels and to initial antihypertensive regimens ( i.e.  ,  calcium antagonist [ Ca-A ] , angiotensin-converting enzyme inhibitor [ ACE-I ] , or angiotensin II receptor antagonist [ ARB ] ) . At the end of February 2004 , 2729 , 1687 , and 971 patients were recruited , r and omized , and followed-up for 12 months or more . Among the 971 patients , mean systolic/diastolic BP levels at r and omization in the Ca-A , ACE-I , and ARB groups were 150/90 , 152/89 , and 151/89 mmHg , respectively . These values reduced after six months of Ca-A- , ACE-I- , and ARB-based treatment ( 133/81 mmHg , 135/80 mmHg , and 134/79 mmHg , respectively ) and further reduced after 12 months ( 131/80 mmHg , 134/79 mmHg , and 132/79 mmHg , respectively ) without any significant differences among groups . In more intensive and less intensive BP-lowering groups , mean systolic/diastolic BP levels at r and omization were 151/90 and 150/89 mmHg , respectively . Although BP levels reduced after 6-month ( 135/80 mmHg and 133/80 mmHg , respectively ) and 12-month treatment ( 133/79 mmHg and 132/80 mmHg , respectively ) in each target group , no significant difference in BP values was observed between groups . These results indicate the necessity of additional interventional strategies to improve the achievement of target BP levels , especially in the more intensive BP-lowering group BACKGROUND Rounding blood pressure ( BP ) to the nearest 10 mmHg ( terminal digit preference ) and selecting for particular values near treatment cut-offs ( number preference ) have both been previously described . Both reduce measurement accuracy , and may have consequences for treatment and survival . AIM To check for number preference in screening for hypertension , and whether this influenced subsequent mortality . DESIGN Prospect i ve case-control screening study . METHODS In the General Practice Hypertensive Study Group ( GPHSG ) , prospect i ve case control study patients ( n=23 574 ) were screened on one occasion for high phase-IV diastolic BP ( DBP4 ) ( > or = 90 mmHg ) . Identified cases were matched with normotensive controls for age , sex , date of screen and ethnic group , and were registered for mortality follow-up ( n=6310 ) . Patients with a high DBP4 had two further readings , and were treated if it remained elevated . RESULTS For DBP4 terminal digit , ' 0 ' was over-represented ( 28.2 % vs. 20 % ) , and the number ' 88 ' was over-represented in both men and women . There was an excess adjusted death rate for females with DBP4 88 - 89 mmHg vs. 90 - 99 mmHg for both cardiovascular ( RR 2.56 , 95%CI 1.43 - 4.56 , p=0.0015 ) and all-cause ( 1.56 , 95%CI 1.06 - 2.29 , p=0.023 ) mortality . For males , the corresponding rates were non-significantly reduced : cardiovascular RR 0.69 , 95%CI 0.42 - 1.14 , p=0.15 ; all-cause RR 0.93 , 95%CI 0.68 - 1.27 , p=0.64 . DISCUSSION The quality of BP measurements should be monitored both in research studies and in clinical practice as part of clinical governance procedures Blood pressure ( BP ) control rates around the world are suboptimal . Part 2 of the National Health and Nutrition Educational Survey ( NHANES ) III indicates that only 27.4 % of hypertensive Americans aged 18 to 74 years have a BP of < 140/90 mm Hg . We wanted to assess BP control during the first 2 years and to describe the baseline characteristics of patients enrolled in the Controlled ONset Verapamil INvestigation of Cardiovascular Endpoints ( CONVINCE ) Study , an international clinical trial that compares outcomes in hypertensive patients r and omized to initial treatment with either controlled-onset extended-release verapamil  or the investigator ’s choice of atenolol or hydrochlorothiazide . At r and omization , BP was < 140/90 mm Hg in only 20.3 % of the 16 602 subjects ( average±SD age 65.6±7.4 years ; 56 % women , 84 % white/7 % black/7 % Hispanic ) . The  average BP  at enrollment was 148/85 mm Hg for patients taking BP medications ( n=13 879 ) and 161/94 mm Hg for previously untreated patients ( n=2723 ) . After medication titration , with a transtelephonic computer that recommended an increase in the dose or number of antihypertensive agents whenever the BP was 140/90 mm Hg , 84.8 % of the subjects attained the goal BP . During 2 years of treatment , BP control was maintained in 67 % to 69 % of the subjects ( 69 % to 71 % for systolic BP of < 140 mm Hg and 90 % for diastolic BP of < 90 mm Hg ) . These data suggest that the control of systolic BP is more difficult than the control of diastolic BP . The US national goal of having 50 % of hypertensives with a BP of < 140/90 mm Hg may be achievable if a forced titration strategy is used . Interested investigators , free care and medications , and well-educated subjects may make the attainment of such a goal easier in the CONVINCE study than in the general population OBJECTIVE Automated blood pressure ( ABP ) devices are ubiquitous at emergency department ( ED ) triage . Previous studies failed to evaluate ABP devices against accepted reference st and ards or demonstrate triage readings as accurate reflections of blood pressure ( BP ) . This study evaluated ED triage measurements made using an ABP device and assessed agreement between triage BP and BP taken under recommended conditions . METHODS A prospect i ve study was conducted at an urban teaching hospital . Patients were enrolled by convenience sampling . Simultaneous automated and manual triage BPs were obtained using one BP cuff with a Y-tube connector . Research assistants were certified in obtaining manual BP as described by the British Hypertension Society ( BHS ) . Patients were placed in a quiet setting , and manual BP was repeated by American Heart Association ( AHA ) st and ards . Data analysis was performed using methods described by Bl and and Altman . The ABP device was assessed using Association for the Advancement of Medical Instrumentation ( AAMI ) and BHS criteria . RESULTS One hundred seventy-one patients were enrolled .  Systolic BP ( sBP ) range was 81 to 218 mm Hg ; diastolic BP ( dBP ) range was 43 to 130 mm Hg . Automated vs. manual sBP difference was 3.8 + /- 11.2 mm Hg ( 95 % confidence interval [ CI ] = 2.1 to 5.4 ) ; dBP difference was 6.6 + /- 9.0 mm Hg ( 95 % CI = -7.9 to -5.2 ) . Manual triage BP vs. AHA st and ard SBP difference was 11.6 + /- 12.8 mm Hg ( 95 % CI = 9.1 to 14.1 ) ; dBP difference was 9.9 + /- 10.4 mm Hg ( 95 % CI = 7.9 to 12.0 ) . The ABP device failed to meet AAMI criteria and received a BHS rating of " D. " Poor operator technique and extraneous patient and operator movement appeared to hamper accuracy . CONCLUSIONS ABP triage measurements show significant discrepancies from a reference st and ard . Repeat measurements following AHA st and ards demonstrate significant decreases in the measured blood pressures BACKGROUND The majority of hypertensive patients do not reach the target blood pressure ( BP ) . We sought to clarify whether intermittent self-monitoring of BP leads to better BP control compared to ordinary treatment in general practice . METHODS Two hundred sixty-nine hypertensive patients participated in this multicenter , r and omized , parallel-group study in primary health care . Home BP was measured in the self-monitoring ( SM ) group at 0 , 2 , 4 , and 6 months , and in the control ( C ) group at 0 and 6 months . The participating physicians were instructed to intensify the antihypertensive therapy when needed . RESULTS At the beginning , both groups had similar home BP levels ( SM 143.1 + /- 17.4/85.3 + /- 7.4 mm Hg v C 143.9 + /- 18.3/85.4 + /- 7.5 mm Hg ) . After 6 months , there were significant decreases in systolic ( P < or= .0001 ) , diastolic ( P < or= .0029 ) , and pulse pressures ( P < or= .021 ) in both groups . Systolic ( -7.8 + /- 13.1 mm Hg v -4.5 + /- 12.2 mm Hg , P = .047 ) and pulse pressure ( -4.7 + /- 9.0 mm Hg v -2.2 + /- 10.0 mm Hg , P = .042 ) decreased significantly more than in the self-monitoring group . The decrease in diastolic pressure was similar in both groups ( SM -3.1 + /- 6.2 mm Hg v C -2.3 + /- 8.3 mm Hg , P = not significant ) . The patients in the SM group reached home BP target more often than those in the C group ( 29 % v 16 % , P = .016 ) . There was a nonsignificant trend toward lower office BP values in the SM group . CONCLUSIONS Self-monitoring decreased systolic and pulse pressure significantly more than ordinary treatment and promoted achievement of target BP . This was most likely due to improved patient compliance and more active treatment by the physicians . Our results suggest that home measurement is useful in the control of hypertension Importance Despite extensive knowledge of hypertension treatment , the prevalence of uncontrolled hypertension is high and increasing in low- and middle-income countries . Objective To test whether a community health worker – led multicomponent intervention would improve blood pressure ( BP ) control among low-income patients with hypertension . Design , Setting , and Participants A cluster r and omized trial was conducted in 18 centers for primary health care within a national public system providing free medications and health care to uninsured patients in Argentina . A total of 1432 low-income adult patients with uncontrolled hypertension were recruited between June 2013 and April 2015 and followed up to October 2016 . Interventions Nine centers ( 743 patients ) were r and omized to the multicomponent intervention , which included a community health worker – led home intervention ( health coaching , home BP monitoring , and BP audit and feedback ) , a physician intervention , and a text-messaging intervention over 18 months .  Nine centers ( 689 patients ) were r and omized to usual care . Main Outcomes and Measures The co primary outcomes were the differences in systolic and diastolic BP changes from baseline to the end of follow-up of patients with hypertension . Secondary outcomes included the proportion of patients with controlled hypertension ( BP < 140/90 mm Hg ) . Three BP measurements were obtained at each of 2 baseline and 2 termination visits using a st and ard protocol , the means of which were used for analyses . Results Of 1432 participants ( mean age , 55.8 years [ SD , 13.3 ] ; 772 women [ 53.0 % ] ) , 1357 ( 94.8 % ) completed the trial . Baseline mean systolic BP was 151.7 mm Hg for the intervention group and 149.8 mm Hg for the usual care group ; the mean diastolic BP was 92.2 mm Hg for the intervention group and 90.1 mm Hg for the usual care  group . Systolic BP reduction from baseline to month 18 was 19.3 mm Hg ( 95 % CI , 17.9 - 20.8 mm Hg ) for the intervention group and 12.7 mm Hg ( 95 % CI , 11.3 - 14.2 mm Hg ) for the usual care group ; the difference in the reduction was 6.6 mm Hg ( 95 % CI , 4.6 - 8.6 ; P < .001 ) . Diastolic BP decreased by 12.2 mm Hg ( 95 % CI , 11.2 - 13.2 mm Hg ) in the intervention group and 6.9 mm Hg ( 95 % CI , 5.9 - 7.8 mm Hg ) in the control group ; the difference in the reduction was 5.4 mm Hg ( 95 % CI , 4.0 - 6.8 mm Hg ; P < .001 ) . The proportion of patients with controlled hypertension increased from 17.0 % at baseline to 72.9 % at 18 months in the intervention group and from 17.6 % to 52.2 % in the usual care group ; the difference in the increase was 20.6 % ( 95 % CI , 15.4%-25.9 % ; P < .001 ) . No adverse events were reported . Conclusions and Relevance Low-income patients in Argentina with uncontrolled hypertension who participated in a community health worker – led multicomponent intervention experienced a greater decrease in systolic and diastolic BP than did patients who received usual care over 18 months . Further research is needed to assess generalizability and cost-effectiveness of this intervention and to underst and which components may have contributed most to the outcome . Trial Registration clinical trials.gov Identifier : The Modification of Diet in Renal Disease Study showed a beneficial effect of a lower-than-usual blood pressure ( BP ) goal on the progression of renal disease in patients with proteinuria . The purpose of the present analyses was to examine the achieved BP , baseline characteristics that helped or hindered achievement of the BP goals , and safety of the BP interventions . Five hundred eighty-five patients with baseline glomerular filtration rate between 13 and 55 mL/min per 1.73 m2 ( 0.22 to 0.92 mL/s per 1.73 m2 ) were r and omly assigned to either a usual or low BP goal ( mean arterial pressure < or = 107 or < or = 92 mm Hg , respectively ) . Few patients had a history of cardiovascular disease . All antihypertensive agents were permitted , but angiotensin-converting enzyme inhibitors ( with or without diuretics ) followed by calcium channel blockers were preferred . The mean ( + /- SD ) of the mean arterial pressures during follow-up in the low and usual BP groups was 93.0 + /- 7.3 and 97.7 + /- 7.7 mm Hg , respectively . Follow-up BP was significantly higher in subgroups of patients with preexisting hypertension , baseline mean arterial pressure > 92 mm Hg , a diagnosis of polycystic kidney disease or glomerular diseases , baseline urinary protein excretion > 1 g/d , age > or = 61 years , and black race . The frequency of medication changes and incidence of symptoms of low BP were greater in the low BP group , but there were no significant differences between BP groups in stop points , hospitalizations , or death . When data from both groups were combined , each 1-mm Hg increase in follow-up systolic BP was associated with a 1.35-times greater risk of hospitalization for cardiovascular or cerebrovascular disease . Lower BP than usually recommended for the prevention of cardiovascular disease is achievable by several medication regimens without serious adverse effects in patients with chronic renal disease without cardiovascular disease . For patients with urinary protein excretion > 1 g/d , target BP should be a mean arterial pressure of < or = 92 mm Hg , equivalent to 125/75 mm Hg The 2014 Evidence -Based Guideline for the Management of  High Blood Pressure In Adults : Report From the Panel Members Appointed to the Eighth Joint National Committee ( JNC 8) recommends several major changes from the JNC 7 report ( 1 , 2 ) . The 2014 guideline is based on a systematic review of r and omized , controlled trials ( RCTs ) by a multidisciplinary panel using a process informed by Institute of Medicine recommendations for guideline development ( 3 ) . Although there was almost unanimous agreement on nearly all recommendations , a minority of the panel ( the authors of this commentary ) disagreed with the recommendation to increase the target systolic blood pressure ( SBP ) from 140 to 150 mm Hg in persons aged 60 years or older without diabetes mellitus ( DM ) or chronic kidney disease ( CKD ) . This target guides both the initiation of therapy and treatment goals . Although this issue has major clinical and public health implication s , the guideline only briefly summarized the concerns underlying the minority opinion to maintain the target of less than 140 mm Hg . The Institute of Medicine recommendation for guideline development encourages guidelines to provide a description and explanation of any differences of opinion regarding the recommendation ( 3 ) . This summarizes the evidence and rationale underlying the minority opinion to maintain the SBP target of 140 mm Hg or lower in persons aged 60 years or older until there is greater certainty of the risks and benefits of a higher target . First , increasing the target will probably reduce the intensity of antihypertensive treatment in a large population at high risk for cardiovascular disease ( CVD ) ( Table 1 ) . The higher SBP goal would apply to some of the groups at highest cardiovascular risk , such as African Americans , hypertensive patients with multiple CVD risk factors other than DM or CKD , and those with clinical CVD . Second , the evidence supporting increasing the SBP target from 140 to 150 mm Hg in persons aged 60 years or older was insufficient and inconsistent with the evidence supporting the panel 's recommendations for an SBP target of less than 140 mm Hg in persons younger than 60 years and those aged 60 years or older with DM or CKD . Third , the higher SBP goal in individuals aged 60 years or older may reverse the decades-long decline in CVD , especially stroke mortality ( 4 ) . In the absence of definitive evidence defining the optimum SBP target , observational studies and RCT data that the panel did not systematic ally review more strongly support the SBP goal of less than 140 mm Hg , especially in high-risk individuals . Other recent guideline groups review ing similar evidence have recommended a goal of less than 140 mm Hg , particularly in persons aged 80 years or younger ( 59 ) . Table 1 . U.S. Cardiovascular Disease Death Rates for Persons Younger and Older Than 65 y Persons Aged 60 Years or Older With Hypertension and SBP Controlled to 140 mm Hg or Lower More than half of the 72 million persons with hypertension in the United States are aged 60 years or older ( 10 , 11 ) . Among these individuals , the 2014 guideline recommends the SBP goal of 140 mm Hg or lower only for those with DM and those younger than 70 years with CKD ( 2 ) . Although the prevalence of hypertension in this age group ( 65 % to 67 % ) did not change between 1999 and 2010 , the percentage with adequate blood pressure control increased from 27.4 % ( 19992000 ) to 50.5 % ( 20112012 ) , with 82.2 % now receiving antihypertensive medications ( 10 , 12 ) . Data from NHANES ( National Health and Nutrition Examination Survey ) from 2001 to 2008 show that among treated and untreated hypertensive adults aged 60 years or older , median SBPs were 136 mm Hg and 152 mm Hg , respectively ( 13 ) , and SBPs have been decreasing in this age group over the past 5 decades ( Figure ) ( 4 ) . Thus , a target of less than 150 mm Hg would likely increase blood pressures in the treated hypertensive population and would suggest that nearly half of the untreated hypertensive patients in this age range should remain untreated . The large population at high risk for CVD , with most currently at an SBP of 140 mm Hg or lower , creates concern that a higher SBP target will adversely affect public health . Figure . Smoothed weighted frequency distribution , median , and 90th percentile of systolic blood pressure for persons aged 60 to 74 y : United States , 19592010 . Reproduced from Lackl and and colleagues ( 4 ) . NHANES = National Health and Nutrition Examination Survey ; NHES = National Health Examination Survey . High Risk in Persons With the Higher Goal Age substantially increases risk for cardiovascular events ( Table 1 ) , so differences in cardiovascular risk do not justify different targets for patients older and younger than 60 years . The risk range for white and African American men aged 60 years is 9 % to 30 % , depending on risk factor profile . For men of both ethnicities who are aged 70 years or older and have SBP controlled to 140 mm Hg , even without clinical CVD or DM , the 10-year risk exceeds 20 % ( 14 ) . Thus , on the basis of absolute risk , using an age threshold of 60 years to define eligibility for less aggressive treatment lacks consistency . Persons aged 60 to 79 years are at higher risk than those who are younger , even if the younger persons have DM . Insufficient Evidence for Differential Hypertension Treatment Benefit for Patients Older and Younger Than 60 Years The 2014 guideline panel failed to identify evidence of differential benefits or harms of treatment using an SBP goal of 140 mm Hg with an age threshold of 60 years . There is little RCT evidence of risk or benefit in treating persons younger than 60 years to this target , except in those with diastolic hypertension . The guideline indicates that no qualifying evidence was found comparing an SBP less than 140 mm Hg to any other SBP goal for persons younger than 60 years ( 2 ) . However , in persons aged 60 years or older , the SHEP ( Systolic Hypertension in the Elderly Program ) trial showed benefit of treating hypertension to an SBP goal between 140 and 145 mm Hg ( Table 2 ) ( 15 ) . HYVET ( Hypertension in the Very Elderly Trial ) found a benefit of an SBP target of less than 150 mm Hg on health outcomes , including mortality in persons aged 80 years or older ( 16 ) . Patients in the HYVET treatment group achieved an SBP of 144 mm Hg at 2 years compared with 159 mm Hg in the control group , and blood pressures continued to decrease in both groups until the end of the trial . Therefore , HYVET and the SHEP trial provide evidence that reducing SBP to around 140 mm Hg has substantial benefit without major harm in older persons . Thus , the best evidence available for an SBP target around 140 mm Hg , which meets the guideline RCT criteria , is in persons older than 60 years . The lack of benefit seen in 2 Japanese trials in older individuals ( JATOS [ Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients ] [ 17 ] and the VALISH [ Valsartan in Elderly Isolated Systolic Hypertension ] trial [ 18 ] ) was cited by some to rationalize the higher SBP target , but these trials were underpowered ( Table 2 ) . The SHEP trial and HYVET together reported 365 strokes and more than 285 coronary heart disease events , whereas JATOS and the VALISH trial only had a combined total of 125 strokes and 67 coronary heart disease events . In addition , the much larger FEVER ( Felodipine Event Reduction ) trial ( 19 ) did not meet criteria for inclusion in the panel 's deliberation ( Table 2 ) . This trial , which was conducted in a Chinese population ( age range , 50 to 79 years ; mean age , 62 years ) , reported a significant 27 % reduction in its primary outcome , as well as significant reductions in all CVD , total mortality , coronary heart disease , and heart failure in patients treated to an SBP of 137 mm Hg with a thiazide diureticcalcium-channel blocker combination versus 143 mm Hg with a thiazide diuretic plus placebo ( 19 ) . Table 2 . Trials Comparing Different Systolic Blood Pressure Thresholds In addition , generalizability of the Japanese trials to other population s of patients older than 60 years , such as African Americans , is uncertain . African Americans are at highest risk for all complications of hypertension and are historically undertreated . Thus , we believe that recommending less aggressive targets in this or other high-risk population s requires stronger justification than the guideline cites . Three recent guidelines from other countries have concluded that the appropriate cut point for an age-related differential SBP goal is 80 years or older ( 57 ) . We agree that this higher treatment target in frail hypertensive patients aged 80 years or older better reflects existing evidence . Safety and Adverse Event Risk in Hypertensive Patients Aged 60 Years or Older Despite the limited number of end points in JATOS and the VALISH trial , their size and duration provide evidence of safety of the SBP target of less than 140 mm Hg . The VALISH investigators concluded that this target was safe in relatively healthy patients aged 70 years or older with isolated systolic hypertension ( 18 ) . In JATOS , adverse events requiring treatment discontinuation were reported in only 36 patients , with no differences in discontinuation rate between groups ( 17 ) . This evidence and the favorable results at slightly higher blood pressures in the SHEP trial and HYVET provide reassurance of the safety of an SBP goal of less than 140 mm Hg in older , nonfrail persons . Other Trial Evidence of Benefit of Treatment at an SBP of 140 mm Hg or Lower Results of the SPS3 ( Secondary Prevention of Small Subcortical Strokes ) trial indicated that an SBP target of less than 130 mm Hg versus 144 mm Hg in 3020 patients ( mean age , 63 years ) reduced subsequent strokes by 19 % ( P= 0.08 ) and hemorrhagic strokes by nearly 50 % ( P < 0.01 ) ( 20 ) . Of note , the FEVER trial reported a 44 % ( P < 0.001 ) reduction in all strokes in a subgroup analysis of patients older than 65 years ( 17 ) . Finally , 2 meta-analyses BACKGROUND Studies have demonstrated that blood pressure ( BP ) control can be improved when clinical pharmacists assist with patient management . The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control . METHODS This was a prospect i ve , cluster r and omized , controlled clinical trial with clinics r and omized to a control group ( n = 3 ) or to an intervention group ( n = 3 ) . The study enrolled 402 patients ( mean age , 58.3 years ) with uncontrolled hypertension .  Clinical pharmacists made drug therapy recommendations to physicians based on national guidelines . Research nurses performed BP measurements and 24-hour BP monitoring . RESULTS The mean ( SD ) guideline adherence scores increased from 49.4 ( 19.3 ) at baseline to 53.4 ( 18.1 ) at 6 months ( 8.1 % increase ) in the control group and from 40.4 ( 22.6 ) at baseline to 62.8 ( 13.5 ) at 6 months ( 55.4 % increase ) in the intervention group ( P = .09 for adjusted between-group comparison ) . The mean BP decreased 6.8/4.5 mm Hg in the control group and 20.7/9.7 mm Hg in the intervention group ( P < .05 for between-group systolic BP comparison ) . The adjusted difference in systolic BP was -12.0 ( 95 % confidence interval [ CI ] , -24.0 to 0.0 ) mm Hg , while the adjusted difference in diastolic BP was -1.8 ( 95 % CI , -11.9 to 8.3 ) mm Hg . The 24-hour BP levels showed similar effect sizes . Blood pressure was controlled in 29.9 % of patients in the control group and in 63.9 % of patients in the intervention group ( adjusted odds ratio , 3.2 ; 95 % CI , 2.0 - 5.1 ; P < .001 ) . CONCLUSIONS A physician and pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates compared with a control group . Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00201019 Introduction : Admission blood pressure ( BP ) assessment is a central component of severity assessment for community acquired pneumonia . The aim of this study was to establish which readily available haemodynamic measure on admission is most useful for predicting severity in patients admitted with community acquired pneumonia . Methods : A prospect i ve observational study of patients admitted with community acquired pneumonia was conducted in Edinburgh , UK . The measurements compared were systolic and diastolic BP , mean arterial pressure and pulse pressure . The outcomes of interest were 30 day mortality and the requirement for mechanical ventilation and /or inotropic support . Results : Admission systolic BP < 90 mm Hg , diastolic BP ⩽60 mm Hg , mean arterial pressure < 70 mm Hg and pulse pressure ⩽40 mm Hg were all associated with increased 30 day mortality and the need for mechanical ventilation and /or inotropic support on multivariate logistic regression . The AUC values for each predictor of 30 day mortality were as follows : systolic BP < 90 mm Hg 0.70 ; diastolic BP ⩽60 mm Hg 0.59 ; mean arterial pressure < 70 mm Hg 0.64 ; and pulse pressure ⩽40 mm Hg 0.60 . The AUC values for each predictor of need for mechanical ventilation and /or inotropic support were as follows : systolic BP < 90 mm Hg 0.70 ; diastolic BP ⩽60 mm Hg 0.68 ; mean arterial pressure < 70 mm Hg 0.69 ; and pulse pressure ⩽40 mm Hg 0.59 . A simplified CRB65 score containing systolic blood pressure < 90 mm Hg alone performed equally well to st and ard CRB65 score ( AUC 0.76 vs 0.74 ) and to the st and ard CURB65 score ( 0.76 vs 0.76 ) for the prediction of 30 day mortality . The simplified CRB65 score was equivalent for prediction of mechanical ventilation and /or inotropic support to st and ard CRB65 ( 0.77 vs 0.77 ) and to CURB65 ( 0.77 vs 0.78 ) . Conclusion : Systolic BP is superior to other haemodynamic predictors of 30 day mortality and need for mechanical ventilation and /or inotropic support in community acquired pneumonia . The CURB65 score can be simplified to a modified CRB65 score by omission of the diastolic BP criterion without compromising its accuracy BACKGROUND When blood pressure (BP)-lowering efficacy is assessed by measurements taken in a clinic setting , angiotensin II-receptor antagonists show similar efficacy to angiotensin-converting enzyme inhibitors and better tolerability . A search of MEDLINE to date , however , reveals no r and omized , double-blind studies using ambulatory BP monitoring ( ABPM ) to compare the BP-lowering efficacy of irbesartan and enalapril in a large number of patients ( > 200 ) with essential hypertension . OBJECTIVE This study compared 24-hour BP reduction and BP control , as assessed by ABPM , in patients with mild to moderate essential hypertension treated with irbesartan or enalapril .  The relative tolerability of the 2 treatments was also evaluated . METHODS This was a multicenter , r and omized , double-blind study in patients with mild to moderate essential hypertension ( office diastolic BP [ DBP ] 90 - 109 mm Hg or systolic BP [ SBP ] 140 - 179 mm Hg ) . After a 3-week , single-blind placebo washout phase , patients with a mean daytime DBP > or = 85 mm Hg , as measured by ABPM between 10 AM and 8 PM , were r and omized to 12 weeks of active treatment with irbesartan or enalapril . Starting doses were 150 and 10 mg/d , respectively , with titration to 300 or 20 mg/d if clinic DBP was > or = 90 mm Hg at week 4 or 8 . Based on clinic measurements , BP control was defined as a BP reading < 140/90 mm Hg after 12 weeks of treatment ; patients achieving a reduction in DBP of > or = 10 mm Hg at 12 weeks were considered responders . The ABPM criterion for BP control , independent of clinic values , was achievement of a daytime BP < 130/85 mm Hg after 12 weeks of treatment ; patients achieving a reduction in 24-hour DBP > or = 5 mm Hg at 12 weeks were considered responders , in dependent of clinic values . RESULTS A total of 238 patients were r and omized to treatment , 115 to irbesartan and 123 to enalapril . The study population was approximately 52.0 % female and 48.0 % male , with a mean ( + /- SD ) age of 52.7 + /- 10.6 years . The study was completed by 111 patients in the irbesartan group ( dose titrated to 300 mg/d in 72.0 % of patients ) and 115 patients in the enalapril group ( dose titrated to 20 mg/d in 76.5 % of patients ) . BP reductions were similar in the 2 groups , both as measured in the clinic ( DBP , 12.7 + /- 8.8 mm Hg irbesartan vs 12.4 + /- 7.4 mm Hg enalapril ; SBP , 19.0 + /- 14.1 mm Hg vs 17.5 + /- 14.0 mm Hg ) and by 24-hour ABPM ( DBP , 9.4 + /- 8.5 mm Hg vs 8.8 + /- 8.5 mm Hg : SBP , 14.7 + /- 14.7 mm Hg vs 12.6 + /- 13.1 mm Hg ) . As assessed by ABPM , rates of BP control were 40.5 % ( 45/111 ) for irbesartan and 33.9 % ( 39/115 ) for enalapril , and the response rates were a respective 71.2 % ( 79/111 ) and 71.3 % ( 82/115 ) . The overall incidence of adverse events ( 40.0 % irbesartan , 51.2 % enalapril ) was not statistically different between groups , although the incidence of adverse events considered probably related to antihypertensive treatment was significantly higher with enalapril than with irbesartan ( 24.6 % vs 9.2 % , respectively ; P = 0.026 ) , essentially because of the higher incidence of cough ( 8.1 % vs 0.9 % ) . CONCLUSIONS As assessed by ABPM , irbesartan 150 to 300 mg/d was as effective in lowering BP and achieving BP control as enalapril 10 to 20 mg/d . Based on the number of treatment-related adverse events , irbesartan was better tolerated than enalapril This study was performed to investigate whether intensive antihypertensive treatment with achieved blood pressure ( BP ) ≤140/90 mm Hg , as compared with st and ard treatment with achieved BP ≤150/90 mm Hg , could further improve cardiovascular outcomes in Chinese hypertensive patients older than 70 years . A total of 724 participants were r and omly assigned to intensive or st and ard antihypertensive treatment . After a mean follow-up of 4 years , the mean achieved BP was 135.7/76.2 mm Hg in the intensive treatment group and 149.7/82.1 mm Hg in the st and ard treatment group . The visit-to-visit variability in systolic BP and diastolic BP was lower in the intensive group than that in the st and ard group . Intensive antihypertensive treatment , compared with the st and ard treatment , decreased total and cardiovascular mortality by 41.7 % and 50.3 % , respectively , and reduced fatal/nonfatal stroke by 42.0 % and heart failure death by 62.7 % . Cox regression analysis indicated that the mean systolic BP ( P=.020 ; 95 % confidence interval , 1.006 - 1.069 ) and the st and ard deviation of systolic BP ( P=.033 ; 95 % confidence interval , 1.006 - 1.151 ) were risk factors for cardiovascular endpoint events . Intensive antihypertensive treatment with achieved 136/76 mm Hg was beneficial for Chinese hypertensive patients older than 70 years . Long-term visit-to-visit variability in systolic BP was positively associated with the incidence of cardiovascular events IMPORTANCE The appropriate treatment target for systolic blood pressure ( SBP ) in older patients with hypertension remains uncertain . OBJECTIVE To evaluate the effects of intensive ( < 120 mm Hg ) compared with st and ard ( < 140 mm Hg ) SBP targets in persons aged 75 years or older with hypertension but without diabetes . DESIGN , SETTING , AND PARTICIPANTS A multicenter , r and omized clinical trial of patients aged 75 years or older who participated in the Systolic Blood Pressure Intervention Trial ( SPRINT ) . Recruitment began on October 20 , 2010 , and follow-up ended on August 20 , 2015 . INTERVENTIONS Participants were r and omized to an SBP target of less than 120 mm Hg ( intensive treatment group , n = 1317 ) or an SBP target of less than 140 mm Hg ( st and ard treatment group , n = 1319 ) . MAIN OUTCOMES AND MEASURES The primary cardiovascular disease outcome was a composite of nonfatal myocardial infa rct ion , acute coronary syndrome not result ing in a myocardial infa rct ion , nonfatal stroke , nonfatal acute decompensated heart failure , and death from cardiovascular causes . All-cause mortality was a secondary outcome . RESULTS Among 2636 participants ( mean age , 79.9 years ; 37.9 % women ) , 2510 ( 95.2 % ) provided complete follow-up data . At a median follow-up of 3.14 years , there was a significantly lower rate of the primary composite outcome ( 102 events in the intensive treatment group vs 148 events in the st and ard treatment group ; hazard ratio [ HR ] , 0.66 [ 95 % CI , 0.51 - 0.85 ] ) and all-cause mortality ( 73 deaths vs 107 deaths , respectively ; HR , 0.67 [ 95 % CI , 0.49 - 0.91 ] ) . The overall rate of serious adverse events was not different between treatment groups ( 48.4 % in the intensive treatment group vs 48.3 % in the st and ard treatment group ; HR , 0.99 [ 95 % CI , 0.89 - 1.11 ] ) . Absolute rates of hypotension were 2.4 % in the intensive treatment group vs 1.4 % in the st and ard treatment group ( HR , 1.71 [ 95 % CI , 0.97 - 3.09 ] ) , 3.0 % vs 2.4 % , respectively , for syncope ( HR , 1.23 [ 95 % CI , 0.76 - 2.00 ] ) , 4.0 % vs 2.7 % for electrolyte abnormalities ( HR , 1.51 [ 95 % CI , 0.99 - 2.33 ] ) , 5.5 % vs 4.0 % for acute kidney injury ( HR , 1.41 [ 95 % CI , 0.98 - 2.04 ] ) , and 4.9 % vs 5.5 % for injurious falls ( HR , 0.91 [ 95 % CI , 0.65 - 1.29 ] ) . CONCLUSIONS AND RELEVANCE Among ambulatory adults aged 75 years or older , treating to an SBP target of less than 120 mm Hg compared with an SBP target of less than 140 mm Hg result ed in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01206062
Treating patients to lower than st and ard BP targets , < /=140 - 160/90 - 100 mmHg , does not reduce mortality or morbidity .
BACKGROUND When treating elevated blood pressure , doctors need to know what blood pressure ( BP ) target they should try to achieve .
The st and ard of clinical practice for some time has been < /= 140 - 160/ 90 - 100 mmHg .
New guidelines are recommending BP targets lower than this st and ard .
It is not known whether attempting to achieve targets lower than the st and ard reduces mortality and morbidity .
OBJECTIVES To determine if lower BP targets ( < /= 135/85 mmHg ) are associated with reduction in mortality and morbidity as compared with st and ard BP targets ( < /= 140 - 160/ 90 - 100 mmHg ) .